Provider Demographics
NPI:1114104502
Name:INTERNAL MEDICINE OF SPRINGFIELD, LLC
Entity Type:Organization
Organization Name:INTERNAL MEDICINE OF SPRINGFIELD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:YOICHI
Authorized Official - Middle Name:CHARLEY
Authorized Official - Last Name:IMAMURA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:939-323-8804
Mailing Address - Street 1:1835 E HIGH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45505-5210
Mailing Address - Country:US
Mailing Address - Phone:937-323-8804
Mailing Address - Fax:888-922-5090
Practice Address - Street 1:1835 E HIGH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45505-5210
Practice Address - Country:US
Practice Address - Phone:937-323-8804
Practice Address - Fax:888-922-5090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-28
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35070875207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH110182531OtherRR MEDICARE
OH2025267Medicaid
OH706669OtherAETNA
OH110182531OtherRAIL ROAD MEDICARE PTAN
OH101046OtherBLACK LUNG
OH34187577027OtherCARESOURCE
OH56969067500OtherWORKERS COMP
OH000000035503OtherANTHEM
OH0403252OtherUHC
OH569690675009OtherMEDICAL MUTUAL
OH110182531OtherRAIL ROAD MEDICARE PTAN
OH0817482Medicare PIN