Provider Demographics
NPI:1740221357
Name:MARJEANNE R FISHER
Entity Type:Organization
Organization Name:MARJEANNE R FISHER
Other - Org Name:NEW IMAGE BREAST PROSTHESIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARJEANNE
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-867-1184
Mailing Address - Street 1:4406 HUSTON RD
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:OH
Mailing Address - Zip Code:45013-9762
Mailing Address - Country:US
Mailing Address - Phone:513-867-1184
Mailing Address - Fax:
Practice Address - Street 1:765 BEISSINGER RD
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45013-9762
Practice Address - Country:US
Practice Address - Phone:513-867-1184
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN137249335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0903982Medicaid
OH0903982Medicaid