Provider Demographics
NPI:1568492809
Name:QUEEN CITY MED MART INC
Entity Type:Organization
Organization Name:QUEEN CITY MED MART INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SAUL
Authorized Official - Middle Name:J
Authorized Official - Last Name:FESMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-733-8100
Mailing Address - Street 1:10780 READING RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45241-2531
Mailing Address - Country:US
Mailing Address - Phone:513-733-8100
Mailing Address - Fax:513-733-8449
Practice Address - Street 1:7725 HOKE RD
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:OH
Practice Address - Zip Code:45315-9725
Practice Address - Country:US
Practice Address - Phone:937-832-4500
Practice Address - Fax:937-832-4550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2544527Medicaid
OH2544527Medicaid