Provider Demographics
NPI:1700828464
Name:COLE, CONRAD R (MD)
Entity Type:Individual
Prefix:DR
First Name:CONRAD
Middle Name:R
Last Name:COLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 BURNET AVENUE MLC 2010
Mailing Address - Street 2:CINCINNATI CHILDREN'S HOSPITAL
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-3026
Mailing Address - Country:US
Mailing Address - Phone:513-636-4415
Mailing Address - Fax:513-636-7805
Practice Address - Street 1:3333 BURNET AVENUE MLC 2010
Practice Address - Street 2:CINCINNATI CHILDREN'S HOSPITAL
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229-3026
Practice Address - Country:US
Practice Address - Phone:513-636-4415
Practice Address - Fax:513-636-7805
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0529072080P0206X
OH35-0788562080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA363382413AMedicaid
GA37BBGWJMedicare ID - Type Unspecified
I05111Medicare UPIN