Healthcare Provider Details

I. General information

NPI: 1447450804
Provider Name (Legal Business Name): COLON & RECTAL DISEASE CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2007
Last Update Date: 01/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10496 MONTGOMERY RD SUITE 204
CINCINNATI OH
45242-5220
US

IV. Provider business mailing address

10496 MONTGOMERY RD SUITE 204
CINCINNATI OH
45242-5220
US

V. Phone/Fax

Practice location:
  • Phone: 513-793-9835
  • Fax: 513-793-9837
Mailing address:
  • Phone: 513-793-9835
  • Fax: 513-793-9837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MAHENDRA MATTA
Title or Position: OWNER
Credential: MD
Phone: 513-793-9835