Provider Demographics
NPI:1487675567
Name:AMBURN, ORVILLE RENE (MD)
Entity Type:Individual
Prefix:
First Name:ORVILLE
Middle Name:RENE
Last Name:AMBURN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:RENE
Other - Middle Name:
Other - Last Name:AMBURN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:250 CASTALIA ST
Mailing Address - Street 2:G
Mailing Address - City:BELLEVUE
Mailing Address - State:OH
Mailing Address - Zip Code:44811
Mailing Address - Country:US
Mailing Address - Phone:419-483-2273
Mailing Address - Fax:419-483-8914
Practice Address - Street 1:250 CASTALIA ST
Practice Address - Street 2:G
Practice Address - City:BELLEVUE
Practice Address - State:OH
Practice Address - Zip Code:44811
Practice Address - Country:US
Practice Address - Phone:419-483-2273
Practice Address - Fax:419-483-8914
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35047110207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0949871Medicaid
F71976Medicare UPIN
OH0949871Medicaid