Provider Demographics
NPI:1063637957
Name:GRETCHEN SEROTA
Entity Type:Organization
Organization Name:GRETCHEN SEROTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GRETCHEN
Authorized Official - Middle Name:O
Authorized Official - Last Name:SEROTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:513-474-9800
Mailing Address - Street 1:8595 BEECHMONT AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45255-4783
Mailing Address - Country:US
Mailing Address - Phone:513-474-9800
Mailing Address - Fax:513-624-0185
Practice Address - Street 1:619 OAK ST
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45206-1613
Practice Address - Country:US
Practice Address - Phone:513-474-9800
Practice Address - Fax:513-474-9805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2009-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH35067381174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0381546Medicaid
OHG39913Medicare UPIN
OH0381546Medicaid