Provider Demographics
NPI:1356348569
Name:JENNINGS, MICHAEL ROBERT (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ROBERT
Last Name:JENNINGS
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 1:237 WILLIAM HOWARD TAFT RD RM 3-064
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45219-2610
Mailing Address - Country:US
Mailing Address - Phone:513-263-8590
Mailing Address - Fax:513-272-0862
Practice Address - Street 1:237 WILLIAM HOWARD TAFT RD RM 3-064
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2610
Practice Address - Country:US
Practice Address - Phone:513-263-8590
Practice Address - Fax:513-272-0362
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY54265207R00000X
OH35049135207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0678539Medicaid
KY64062169Medicaid
OHJE0835765Medicare PIN