Provider Demographics
NPI:1578538955
Name:JENNINGS, MARK R (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:R
Last Name:JENNINGS
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 1:3300 MERCY HEALTH BLVD STE 2010
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45211-1103
Mailing Address - Country:US
Mailing Address - Phone:513-961-4335
Mailing Address - Fax:513-872-5769
Practice Address - Street 1:3300 MERCY HEALTH BLVD STE 2010
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45211-1103
Practice Address - Country:US
Practice Address - Phone:513-961-4335
Practice Address - Fax:513-872-5769
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35085981208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100056850Medicaid
IN200515190AMedicaid
KY64103476Medicaid
OH2580407Medicaid
P00274332OtherRAILROAD MEDICARE
IN200515190AMedicaid
KY7100056850Medicaid