Provider Demographics
NPI:1205197985
Name:WRIGHT STATE PHYSICIANS INC
Entity Type:Organization
Organization Name:WRIGHT STATE PHYSICIANS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARCO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-245-7100
Mailing Address - Street 1:725 UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324
Mailing Address - Country:US
Mailing Address - Phone:937-245-7100
Mailing Address - Fax:937-245-7999
Practice Address - Street 1:725 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45435-0001
Practice Address - Country:US
Practice Address - Phone:937-245-7100
Practice Address - Fax:937-245-7999
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WRIGHT STATE PHYSICIANS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-05-30
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH821388207N00000X, 207Q00000X, 207V00000X, 207X00000X, 207ZD0900X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathologyGroup - Multi-Specialty
No208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1114920329OtherPARENT GROUP NPI
OH0914443Medicaid
OH821388OtherBUSINESS LICENSURE
OHWR9256604Medicare PIN
OH0654700011Medicare NSC