Provider Demographics
NPI:1013532746
Name:BISHOP, AUSTIN
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:
Last Name:BISHOP
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4271 GLENWAY AVE
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:OH
Mailing Address - Zip Code:45236-3631
Mailing Address - Country:US
Mailing Address - Phone:513-310-9191
Mailing Address - Fax:
Practice Address - Street 1:4271 GLENWAY AVE
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:OH
Practice Address - Zip Code:45236-3631
Practice Address - Country:US
Practice Address - Phone:513-310-9191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-09
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0402261Medicaid