Provider Demographics
NPI:1790777688
Name:NELSON, MAUREEN (DO)
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 633390
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-3390
Mailing Address - Country:US
Mailing Address - Phone:800-594-1876
Mailing Address - Fax:
Practice Address - Street 1:2801 BAY PARK DR
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:OH
Practice Address - Zip Code:43616-4920
Practice Address - Country:US
Practice Address - Phone:419-690-7900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-17
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34007795207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000260317OtherANTHEM
OH2387171Medicaid
MI4522424Medicaid
OHNE7307431Medicare ID - Type Unspecified
OH2387171Medicaid
OHP00676875Medicare PIN
MI4522424Medicaid
MIMI1174016Medicare PIN
MIP00711056Medicare PIN