=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679779821
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INDIAN CREEK FAMILY HEALTH ROSS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2007
-----------------------------------------------------
Last Update Date | 09/11/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2449 ROSS MILLVILLE RD
-----------------------------------------------------
City | HAMILTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-523-2340
-----------------------------------------------------
Fax | 513-523-5080
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10 N LOCUST ST P O BOX 700
-----------------------------------------------------
City | OXFORD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45056-1192
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-523-2340
-----------------------------------------------------
Fax | 513-523-5080
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | JULIE BROERING
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 513-523-5080
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------