MEDICARE: CITY OF CINCINNATI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1316294119
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CITY OF CINCINNATI

Provider Business Mailing Address
First Line	:	3101 BURNET AVE
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45229-3014
Country	:	US
Telephone Number	:	513-357-7288
Fax Number	:

Provider Business Practice Location Address
First Line	:	1930 FRICKE RD
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45225-1200
Country	:	US
Telephone Number	:	513-357-7208
Fax Number	:

Authorized Official
Title or Position	:	HEALTH COMMISSIONER
Name	:	DR. NOBLE MASERU
Credential	:	PHD
Telephone Number	:	513-357-7280

Provider Enumeration Date	:	08/10/2012
Last Update Date	:	08/10/2012

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1902905656 — DR. RONALD JOHN GRYCKO DDS
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Directions to “CITY OF CINCINNATI ” Practice Location

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