=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700872728
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | QUALIFIED EMERGENCY SPECIALISTS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2005
-----------------------------------------------------
Last Update Date | 10/03/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10500 MONTGOMERY RD
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45242-4402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-865-1307
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10506 MONTGOMERY RD SUITE #209
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45242-4487
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-865-1307
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MICHAEL J BAIN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 513-865-9040
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------