Provider Demographics
NPI:1215111539
Name:JENNIFER B MANDERS MD LLC
Entity type:Organization
Organization Name:JENNIFER B MANDERS MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:B
Authorized Official - Last Name:MANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:513-272-1999
Mailing Address - Street 1:4460 RED BANK RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45227-2172
Mailing Address - Country:US
Mailing Address - Phone:513-272-1999
Mailing Address - Fax:
Practice Address - Street 1:4460 RED BANK RD
Practice Address - Street 2:SUITE 120
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45227-2172
Practice Address - Country:US
Practice Address - Phone:513-272-1999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-21
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-086334208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200932170AMedicaid
OH9372801Medicare PIN