Provider Demographics
NPI:1275639908
Name:MALE REPRODUCTIVE MEDICINE OF SOUTHWEST OHIO
Entity Type:Organization
Organization Name:MALE REPRODUCTIVE MEDICINE OF SOUTHWEST OHIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENI
Authorized Official - Middle Name:R
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-435-6136
Mailing Address - Street 1:2773 ORCHARD RUN RD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45449-2831
Mailing Address - Country:US
Mailing Address - Phone:937-435-3110
Mailing Address - Fax:937-435-6135
Practice Address - Street 1:5692 FAR HILLS AVE
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-2239
Practice Address - Country:US
Practice Address - Phone:937-434-9901
Practice Address - Fax:937-434-9107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-086518208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
9364091Medicare PIN