Provider Demographics
NPI:1528062890
Name:ENTIS, GREGORY N (MD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:N
Last Name:ENTIS
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 1:4685 FOREST AVE STE C
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45212-3359
Mailing Address - Country:US
Mailing Address - Phone:513-246-7800
Mailing Address - Fax:513-246-7852
Practice Address - Street 1:8245 NORTHCREEK DR
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45236-2283
Practice Address - Country:US
Practice Address - Phone:513-246-7000
Practice Address - Fax:513-246-5284
Is Sole Proprietor?:No
Enumeration Date:2005-06-02
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35039575E174400000X
OH35.039575207K00000X, 207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
No174400000XOther Service ProvidersSpecialist
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0459329Medicaid
OH0402853Medicaid
OHH269470Medicare PIN
OHA79713Medicare UPIN
OHEN0814401Medicare ID - Type UnspecifiedGLENWAY OFFICE
OHA79713Medicare UPIN
OH000000020972OtherANTHEM
OH311475157001OtherTRI-CARE
OHAL9287292Medicare ID - Type UnspecifiedGROUP-GLENWAY
OH31147515700OtherWORKERS COMP GROUP
OH030003160OtherMEDICARE RR
OH0402853Medicaid
OH311475157OtherEIN
OHEN0814402Medicare ID - Type UnspecifiedMONTGOMERY OFFICE
OH0459329Medicaid
OHH269470Medicare PIN