Provider Demographics
NPI:1407810807
Name:BORT, THADDEUS MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:THADDEUS
Middle Name:MICHAEL
Last Name:BORT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:237 WILLIAM HOWARD TAFT RD FL 2
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45219-2610
Mailing Address - Country:US
Mailing Address - Phone:513-263-1532
Mailing Address - Fax:513-263-8622
Practice Address - Street 1:3260 WESTBOURNE DR
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45248-5107
Practice Address - Country:US
Practice Address - Phone:513-674-1400
Practice Address - Fax:513-206-1904
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-05-2475207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0623801Medicaid
OH0623801Medicaid
OHB00585986Medicare ID - Type Unspecified