Healthcare Provider Details

I. General information

NPI: 1699228239
Provider Name (Legal Business Name): KENWOOD DERMATOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2016
Last Update Date: 10/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8250 KENWOOD CROSSING WAY SUITE 101
CINCINNATI OH
45236-3668
US

IV. Provider business mailing address

8250 KENWOOD CROSSING WAY STE 101
CINCINNATI OH
45236-3669
US

V. Phone/Fax

Practice location:
  • Phone: 513-745-5510
  • Fax:
Mailing address:
  • Phone: 513-745-5510
  • Fax: 513-745-5515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number35.097237
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number35.097237
License Number StateOH

VIII. Authorized Official

Name: KARA SHAH
Title or Position: PRESIDENT
Credential: MD
Phone: 513-745-5510