=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033197629
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BAKKIAM SUBBIAH MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2006
-----------------------------------------------------
Last Update Date | 01/10/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 234 GOODMAN ST
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45219-2364
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-475-8730
-----------------------------------------------------
Fax | 513-475-8033
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2830 VICTORY PKWY
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45206-1785
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-585-6200
-----------------------------------------------------
Fax | 513-245-3672
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0600X
-----------------------------------------------------
Taxonomy Name | Clinical Neurophysiology Physician
-----------------------------------------------------
License Number | 036049109
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | 35123625
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2084N0600X
-----------------------------------------------------
Taxonomy Name | Clinical Neurophysiology Physician
-----------------------------------------------------
License Number | 19525
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | ME88557
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | 19525
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | 036049109
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 2084N0600X
-----------------------------------------------------
Taxonomy Name | Clinical Neurophysiology Physician
-----------------------------------------------------
License Number | 35123625
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 2084N0600X
-----------------------------------------------------
Taxonomy Name | Clinical Neurophysiology Physician
-----------------------------------------------------
License Number | ME88557
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------