Healthcare Provider Details

I. General information

NPI: 1487921920
Provider Name (Legal Business Name): WHOLE HEALTH MEDICAL GROUP OF OHIO PROF CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2011
Last Update Date: 05/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11530 NORTHLAKE DR
CINCINNATI OH
45249-1642
US

IV. Provider business mailing address

16906 COLLECTION CENTER DR
CHICAGO IL
60693-0169
US

V. Phone/Fax

Practice location:
  • Phone: 513-530-4104
  • Fax: 513-748-3685
Mailing address:
  • Phone: 877-865-9013
  • Fax: 513-748-3685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JAMES THIEL
Title or Position: OWNER
Credential: M.D.
Phone: 615-468-6548