Provider Demographics
NPI:1508040171
Name:GENERATIONS FAMILY MEDICINE OF SOUTHWEST OHIO LLC
Entity Type:Organization
Organization Name:GENERATIONS FAMILY MEDICINE OF SOUTHWEST OHIO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LEAH
Authorized Official - Middle Name:
Authorized Official - Last Name:AVERA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:513-217-5850
Mailing Address - Street 1:PO BOX 635893
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5893
Mailing Address - Country:US
Mailing Address - Phone:513-721-3504
Mailing Address - Fax:513-345-6281
Practice Address - Street 1:1042 SUMMITT SQ
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45042-3400
Practice Address - Country:US
Practice Address - Phone:513-217-5850
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-19
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHGE9374571Medicare PIN