Provider Demographics
NPI:1639126220
Name:MEDICAL CENTER AT ELIZABETH PLACE LLC
Entity Type:Organization
Organization Name:MEDICAL CENTER AT ELIZABETH PLACE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-660-8751
Mailing Address - Street 1:PO BOX 88265
Mailing Address - Street 2:DEPARTMENT A
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60680-1265
Mailing Address - Country:US
Mailing Address - Phone:937-660-3077
Mailing Address - Fax:937-660-3088
Practice Address - Street 1:1 ELIZABETH PLACE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-3455
Practice Address - Country:US
Practice Address - Phone:937-660-3077
Practice Address - Fax:937-660-3088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2723959Medicaid
OH2723959Medicaid