=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003204967
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OHIO PODIATRIC PHYSICIANS AND SURGEONS GROUP, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/30/2014
-----------------------------------------------------
Last Update Date | 12/30/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7529 STATE RD SUITE B
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45255-6409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-232-6600
-----------------------------------------------------
Fax | 513-232-7529
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7529 STATE RD SUITE B
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45255-6409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-232-6600
-----------------------------------------------------
Fax | 513-232-7529
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PODIATRIST
-----------------------------------------------------
Name | DR. BRIAN A. KUVSHINIKOV
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 513-232-6600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 36-003316
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 213ES0131X
-----------------------------------------------------
Taxonomy Name | Foot Surgery Podiatrist
-----------------------------------------------------
License Number | 36-003316
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 213EP1101X
-----------------------------------------------------
Taxonomy Name | Primary Podiatric Medicine Podiatrist
-----------------------------------------------------
License Number | 36-003316
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------