Provider Demographics
NPI:1710360474
Name:ASSURANCE HEALTH CINCINNATI, LLC
Entity Type:Organization
Organization Name:ASSURANCE HEALTH CINCINNATI, LLC
Other - Org Name:ASSURANCE HEALTH WILMINGTON
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:D
Authorized Official - Last Name:SMALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-372-6611
Mailing Address - Street 1:11690 GROOMS RD
Mailing Address - Street 2:
Mailing Address - City:BLUE ASH
Mailing Address - State:OH
Mailing Address - Zip Code:45242-1412
Mailing Address - Country:US
Mailing Address - Phone:765-374-6044
Mailing Address - Fax:765-374-6043
Practice Address - Street 1:11690 GROOMS RD
Practice Address - Street 2:
Practice Address - City:BLUE ASH
Practice Address - State:OH
Practice Address - Zip Code:45242-1412
Practice Address - Country:US
Practice Address - Phone:513-469-7800
Practice Address - Fax:513-469-9800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-30
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH07-7512283Q00000X
OH07-7517283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH07-7512OtherSTATE LICENSE
OH75-7517OtherWILMINGTON STATE LICENSE NUMBER
OH0193925Medicaid
OH07-7512OtherSTATE LICENSE