Provider Demographics
NPI:1659347029
Name:BLUE ASH INTERNAL MEDICINE, LLC
Entity Type:Organization
Organization Name:BLUE ASH INTERNAL MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:E
Authorized Official - Last Name:RISSOVER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:513-745-9993
Mailing Address - Street 1:4260 GLENDALE MILFORD ROAD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45242
Mailing Address - Country:US
Mailing Address - Phone:513-745-9993
Mailing Address - Fax:513-745-9269
Practice Address - Street 1:4260 GLENDALE MILFORD ROAD
Practice Address - Street 2:SUITE 101
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45242
Practice Address - Country:US
Practice Address - Phone:513-745-9993
Practice Address - Fax:513-745-9269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-27
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2278771Medicaid
OHBL9318561Medicare PIN