Healthcare Provider Details

I. General information

NPI: 1548297807
Provider Name (Legal Business Name): QUEEN CITY GENERAL & VASCULAR SURGEONS GROUP LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 11/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7502 STATE RD STE. 1180
CINCINNATI OH
45255-2800
US

IV. Provider business mailing address

1270 SOLUTIONS CENTER PO BOX 771270
CHICAGO IL
60677-1002
US

V. Phone/Fax

Practice location:
  • Phone: 513-232-8181
  • Fax: 513-624-2964
Mailing address:
  • Phone: 513-542-6898
  • Fax: 513-542-7972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. PEGGY ERTEL
Title or Position: PRACTICE MANAGER
Credential:
Phone: 513-232-8181