Provider Demographics
NPI:1588659841
Name:HOSPITAL SERVICES MEDICAL GROUP OF CLARK COUNTY INC
Entity Type:Organization
Organization Name:HOSPITAL SERVICES MEDICAL GROUP OF CLARK COUNTY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:W
Authorized Official - Last Name:KOLODZIK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:800-726-3627
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:937-619-4342
Practice Address - Street 1:2615 E HIGH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45505-1412
Practice Address - Country:US
Practice Address - Phone:937-325-0531
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-13
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1429529207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH203409OtherEEOICP GRP PROVIDER #
OH202763100OtherDOL GRP PROVIDER NUMBER
OH2490844Medicaid
OH020406300OtherFBLP GRP PROVIDER NUMBER
OH2490844Medicaid
OH9343331Medicare PIN