Healthcare Provider Details

I. General information

NPI: 1396764528
Provider Name (Legal Business Name): NORTHEAST CENTER FOR WOMEN'S HEALTH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 04/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11135 MONTGOMERY RD
CINCINNATI OH
45249-2338
US

IV. Provider business mailing address

11135 MONTGOMERY RD
CINCINNATI OH
45249-2338
US

V. Phone/Fax

Practice location:
  • Phone: 513-793-2220
  • Fax: 513-793-5933
Mailing address:
  • Phone: 513-793-2220
  • Fax: 513-793-5933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JON RICHARD FACKLER
Title or Position: CO-OWNER
Credential: MD
Phone: 513-793-2220