Healthcare Provider Details

I. General information

NPI: 1073668315
Provider Name (Legal Business Name): ITM GERIATRIC SPECIALIST, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 10/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

619 OAK ST RM 645
CINCINNATI OH
45206-1613
US

IV. Provider business mailing address

PO BOX 635627
CINCINNATI OH
45263-0044
US

V. Phone/Fax

Practice location:
  • Phone: 513-569-6780
  • Fax: 513-569-6555
Mailing address:
  • Phone: 513-891-7574
  • Fax: 513-891-1039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. IMRAN T MINHAS
Title or Position: OWNER
Credential: MD
Phone: 513-569-6780