Provider Demographics
NPI:1710307319
Name:QUEEN CITY MED MART LLC
Entity Type:Organization
Organization Name:QUEEN CITY MED MART LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:P
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 1:5045 CROOKSHANK RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45238-3301
Practice Address - Country:US
Practice Address - Phone:513-347-9700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-22
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies