Provider Demographics
NPI:1558309880
Name:OSBORN, GARY L (DO)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:L
Last Name:OSBORN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4750 HEMPSTEAD STATION DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-5164
Mailing Address - Country:US
Mailing Address - Phone:800-875-0136
Mailing Address - Fax:937-619-4231
Practice Address - Street 1:1000 MCKINLEY PARK DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-6399
Practice Address - Country:US
Practice Address - Phone:740-383-8700
Practice Address - Fax:740-383-8517
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34004155207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000224124OtherBCBS MARION
OH0647027Medicaid
OH930116144OtherRR MEDICARE MARION
E92030Medicare UPIN
OH930116144OtherRR MEDICARE MARION