Healthcare Provider Details

I. General information

NPI: 1700109568
Provider Name (Legal Business Name): STACY C OSBORNE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2010
Last Update Date: 03/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5521 MONTGOMERY RD
CINCINNATI OH
45212-1848
US

IV. Provider business mailing address

5521 MONTGOMERY RD
CINCINNATI OH
45212-1848
US

V. Phone/Fax

Practice location:
  • Phone: 513-351-6300
  • Fax: 513-351-9951
Mailing address:
  • Phone: 513-351-6300
  • Fax: 513-351-9951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number36002140
License Number StateOH

VIII. Authorized Official

Name: STACY OSBORNE
Title or Position: DPM/OWNER
Credential:
Phone: 513-351-6300