QUEEN CITY GENERAL & VASCULAR SURGEONS GROUP LTD

Provider Demographics

• NPI: 1548297807
• Name: QUEEN CITY GENERAL & VASCULAR SURGEONS GROUP LTD
• Entity type: Organization
• Organization Name: QUEEN CITY GENERAL & VASCULAR SURGEONS GROUP LTD
• Other - Org Name: <UNAVAIL>
• Authorized Official - Title/Position: PRACTICE MANAGER
• Authorized Official - Prefix: MRS
• Authorized Official - First Name: PEGGY
• Authorized Official - Last Name: ERTEL
• Authorized Official - Phone: 513-232-8181
• Mailing Address - Street 1: 1270 SOLUTIONS CENTER
• Mailing Address - Street 2: PO BOX 771270
• Mailing Address - City: CHICAGO
• Mailing Address - State: IL
• Mailing Address - Zip Code: 60677-1002
• Mailing Address - Country: US
• Mailing Address - Phone: 513-542-6898
• Mailing Address - Fax: 513-542-7972
• Practice Address - Street 1: 7502 STATE RD
• Practice Address - Street 2: STE. 1180
• Practice Address - City: CINCINNATI
• Practice Address - State: OH
• Practice Address - Zip Code: 45255-2800
• Practice Address - Country: US
• Practice Address - Phone: 513-232-8181
• Practice Address - Fax: 513-624-2964
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2006-06-26
• Last Update Date: 2011-11-22

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	208600000X	Allopathic & Osteopathic Physicians	Surgery		Group - Multi-Specialty
No	2086S0129X	Allopathic & Osteopathic Physicians	Surgery	Vascular Surgery	Group - Multi-Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
IN	200293310B	Medicaid
OH	2066026	Medicaid
OH	2066035	Medicaid
OH	2066044	Medicaid
IN	200293310E	Medicaid
OH	2065867	Medicaid
OH	2324336	Medicaid
IN	200293310A	Medicaid
IN	200293310C	Medicaid
IN	200293310D	Medicaid
OH	CD8400	Other	RAILROAD MEDICARE
OH	2066053	Medicaid
OH	2066017	Medicaid
OH	2324336	Medicaid
OH	9292193	Medicare PIN
OH	9292194	Medicare PIN
OH	9292196	Medicare PIN
OH	2066026	Medicaid
OH	9292197	Medicare PIN
OH	9292191	Medicare PIN