Healthcare Provider Details

I. General information

NPI: 1417283862
Provider Name (Legal Business Name): CINCINNATI INSTITUE OF PLASTIC SURGERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2009
Last Update Date: 10/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10577 MONTGOMERY RD
CINCINNATI OH
45242-4451
US

IV. Provider business mailing address

10577 MONTGOMERY RD
CINCINNATI OH
45242-4451
US

V. Phone/Fax

Practice location:
  • Phone: 513-793-5772
  • Fax: 513-792-5384
Mailing address:
  • Phone: 513-793-5772
  • Fax: 513-792-5384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number35057586
License Number StateOH

VIII. Authorized Official

Name: DR. PETER J. MCKENNA
Title or Position: OWNER
Credential: M.D.
Phone: 513-793-5772