Healthcare Provider Details

I. General information

NPI: 1043597404
Provider Name (Legal Business Name): MOLLY A TATUM D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MOLLY A MCGRAW D.O.

II. Dates (important events)

Enumeration Date: 11/12/2011
Last Update Date: 11/09/2023
Certification Date: 11/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3205 WOODMAN DR
DAYTON OH
45420-1143
US

IV. Provider business mailing address

6480 HARRISON AVE STE 201
CINCINNATI OH
45247-7961
US

V. Phone/Fax

Practice location:
  • Phone: 937-298-4417
  • Fax: 937-298-8260
Mailing address:
  • Phone: 513-713-1779
  • Fax: 138-549-9215

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number34.012776
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: