MEDICARE: CENTRAL CINCINNATI GROUP MEDICAL PRACTICE

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	207R00000X	Internal Medicine Physician	35-029778	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1437293545
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRAL CINCINNATI GROUP MEDICAL PRACTICE

Provider Business Mailing Address
First Line	:	791 E MCMILLAN ST
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45206-1943
Country	:	US
Telephone Number	:	513-751-2221
Fax Number	:	513-751-8804

Provider Business Practice Location Address
First Line	:	791 E MCMILLAN ST
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45206-1943
Country	:	US
Telephone Number	:	513-751-2221
Fax Number	:	513-751-8804

Authorized Official
Title or Position	:	PRESIDENT & CEO
Name	:	DR. CHARLES O DILLARD
Credential	:	M.D.
Telephone Number	:	513-751-2221

Provider Enumeration Date	:	02/20/2007
Last Update Date	:	08/22/2020

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