Healthcare Provider Details

I. General information

NPI: 1164859948
Provider Name (Legal Business Name): HEALTHSPAN INTEGRATED CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2013
Last Update Date: 10/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 STATE ROUTE 59 SUITE 28
KENT OH
44240-7105
US

IV. Provider business mailing address

615 ELSINORE PL
CINCINNATI OH
45202-1459
US

V. Phone/Fax

Practice location:
  • Phone: 216-265-8810
  • Fax: 216-265-8890
Mailing address:
  • Phone: 513-639-2722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. DAVID A NOWISKI
Title or Position: CFO
Credential:
Phone: 513-639-2722