MEDICARE: HEALTHSPAN INTEGRATED CARE

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	208000000X	Pediatrics Physician
2	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1538596390
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEALTHSPAN INTEGRATED CARE

Provider Business Mailing Address
First Line	:	615 ELSINORE PL
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45202-1459
Country	:	US
Telephone Number	:	513-639-2722
Fax Number	:

Provider Business Practice Location Address
First Line	:	8930 CANYON FALLS
Second Line	:
City	:	TWINSBURG
State	:	OH
Zip	:	44087
Country	:	US
Telephone Number	:	216-265-8810
Fax Number	:	216-265-8890

Authorized Official
Title or Position	:	CFO
Name	:	MR. DAVID A NOWISKI
Credential	:
Telephone Number	:	513-639-2722

Provider Enumeration Date	:	10/10/2013
Last Update Date	:	10/10/2013

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