MEDICARE: CINCINNATI INSTITUE OF PLASTIC SURGERY, LLC

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	208200000X	Plastic Surgery Physician	35057586	OH

General Provider Information

NPI Number	:	1417283862
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CINCINNATI INSTITUE OF PLASTIC SURGERY, LLC

Provider Business Mailing Address
First Line	:	10577 MONTGOMERY RD
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45242-4451
Country	:	US
Telephone Number	:	513-793-5772
Fax Number	:	513-792-5384

Provider Business Practice Location Address
First Line	:	10577 MONTGOMERY RD
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45242-4451
Country	:	US
Telephone Number	:	513-793-5772
Fax Number	:	513-792-5384

Authorized Official
Title or Position	:	OWNER
Name	:	DR. PETER J. MCKENNA
Credential	:	M.D.
Telephone Number	:	513-793-5772

Provider Enumeration Date	:	10/20/2009
Last Update Date	:	10/20/2009

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