Provider Demographics
NPI:1508287368
Name:PERSONIMED
Entity Type:Organization
Organization Name:PERSONIMED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:CHERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:COUSINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-800-2188
Mailing Address - Street 1:4224 SR 276
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:OH
Mailing Address - Zip Code:45103-2221
Mailing Address - Country:US
Mailing Address - Phone:513-800-2188
Mailing Address - Fax:
Practice Address - Street 1:1001 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:OH
Practice Address - Zip Code:45176-1146
Practice Address - Country:US
Practice Address - Phone:513-800-2188
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BNC COLLABORATIVE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-12-21
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty