Healthcare Provider Details

I. General information

NPI: 1861887895
Provider Name (Legal Business Name): BLAKE MATESIC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2015
Last Update Date: 07/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 GOODMAN ST
CINCINNATI OH
45219-2364
US

IV. Provider business mailing address

2830 VICTORY PKWY
CINCINNATI OH
45206-1785
US

V. Phone/Fax

Practice location:
  • Phone: 513-475-8000
  • Fax: 513-584-0468
Mailing address:
  • Phone: 513-245-3104
  • Fax: 513-585-5511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number34014033
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: