Provider Demographics
NPI:1164523882
Name:SIDNEY MEDICAL GROUP INC
Entity Type:Organization
Organization Name:SIDNEY MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-492-9128
Mailing Address - Street 1:322 SECOND AVENUE
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:OH
Mailing Address - Zip Code:45365
Mailing Address - Country:US
Mailing Address - Phone:937-492-9128
Mailing Address - Fax:937-497-0820
Practice Address - Street 1:322 SECOND AVENUE
Practice Address - Street 2:
Practice Address - City:SIDNEY
Practice Address - State:OH
Practice Address - Zip Code:45365
Practice Address - Country:US
Practice Address - Phone:937-492-9128
Practice Address - Fax:937-497-0820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0305539Medicaid
OH2435930Medicaid
OH0905784Medicaid
OH2435930Medicaid
H22110Medicare UPIN
D31112Medicare UPIN
0424622Medicare ID - Type UnspecifiedROBERT MILLER INDIV #
4120531Medicare ID - Type UnspecifiedMARK YOUNG INDIV #