MEDICARE: PERSONIMED

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	363LF0000X	Family Nurse Practitioner

General Provider Information

NPI Number	:	1508287368
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PERSONIMED

Provider Business Mailing Address
First Line	:	4224 SR 276
Second Line	:
City	:	BATAVIA
State	:	OH
Zip	:	45103-2221
Country	:	US
Telephone Number	:	513-800-2188
Fax Number	:

Provider Business Practice Location Address
First Line	:	1001 W MAIN ST
Second Line	:
City	:	WILLIAMSBURG
State	:	OH
Zip	:	45176-1146
Country	:	US
Telephone Number	:	513-800-2188
Fax Number	:

Authorized Official
Title or Position	:	COO
Name	:	CHERRY COUSINS
Credential	:
Telephone Number	:	513-800-2188

Provider Enumeration Date	:	12/21/2013
Last Update Date	:	08/04/2014

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Directions to “PERSONIMED ” Practice Location

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