Healthcare Provider Details

I. General information

NPI: 1326534264
Provider Name (Legal Business Name): LAURA CLINE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2018
Last Update Date: 07/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5710 WOOSTER PIKE STE 102
CINCINNATI OH
45227-4520
US

IV. Provider business mailing address

10649 N PARK AVE
INDIANAPOLIS IN
46280-1019
US

V. Phone/Fax

Practice location:
  • Phone: 813-713-0069
  • Fax:
Mailing address:
  • Phone: 317-728-8818
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01039640A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number01039640A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number01039640A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: