Healthcare Provider Details

I. General information

NPI: 1831571025
Provider Name (Legal Business Name): AMRUTA H PANWALA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2015
Last Update Date: 03/02/2023
Certification Date: 03/02/2023
Deactivation Date: 02/02/2016
Reactivation Date: 03/07/2016

III. Provider practice location address

3188 BELLEVUE AVE
CINCINNATI OH
45219-2369
US

IV. Provider business mailing address

PO BOX 636256
CINCINNATI OH
45263-6256
US

V. Phone/Fax

Practice location:
  • Phone: 513-558-7581
  • Fax: 513-558-4399
Mailing address:
  • Phone: 513-585-6200
  • Fax: 513-245-3672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number59550
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number35.146852
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number59550
License Number StateTN
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number60359
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: