=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093769515
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GREGORY S. NEWKIRK PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2006
-----------------------------------------------------
Last Update Date | 09/19/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 E BUSINESS WAY STE A
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45241-2374
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-354-3700
-----------------------------------------------------
Fax | 513-354-3705
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6480 HARRISON AVE STE 201
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45247-7961
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-354-7785
-----------------------------------------------------
Fax | 513-354-7651
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | 1807
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------