Provider Demographics
NPI:1114325321
Name:EDGAR SANTILLAN MD LLC
Entity Type:Organization
Organization Name:EDGAR SANTILLAN MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:R
Authorized Official - Last Name:SANTILLAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-556-4324
Mailing Address - Street 1:PO BOX 771861
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48277-1861
Mailing Address - Country:US
Mailing Address - Phone:937-556-4324
Mailing Address - Fax:937-350-6477
Practice Address - Street 1:2400 MIAMI VALLEY DR
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-4774
Practice Address - Country:US
Practice Address - Phone:937-556-4324
Practice Address - Fax:937-439-3786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-22
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35075548207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0117021Medicaid
OHDV9529Medicare PIN
OHH427890Medicare PIN