Provider Demographics
NPI:1891729158
Name:ANNENBERG, ALAN J (MD)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:J
Last Name:ANNENBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4030 SMITH RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45209-1957
Mailing Address - Country:US
Mailing Address - Phone:513-421-3494
Mailing Address - Fax:513-345-2606
Practice Address - Street 1:4030 SMITH RD
Practice Address - Street 2:SUITE 300
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45209-1957
Practice Address - Country:US
Practice Address - Phone:513-421-3494
Practice Address - Fax:513-345-2606
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35049257A208600000X, 2086S0129X
KY25980208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
49257OtherCHOICE CARE/HUMANA
310804060032OtherCARESOURCE
OH0695636Medicaid
1702166OtherUNITED HEALTHCARE
IN200001270Medicaid
8330OtherKY BCBS
000000211187OtherANTHEM
000000211187OtherANTHEM
8330OtherKY BCBS
A17324Medicare UPIN
1702166OtherUNITED HEALTHCARE
310804060032OtherCARESOURCE
KY0677811Medicare PIN