Provider Demographics
NPI:1659726768
Name:PROVIDENCE MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:PROVIDENCE MEDICAL GROUP, INC.
Other - Org Name:PMG VASCULAR IMAGING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:BECKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-297-8999
Mailing Address - Street 1:2912 SPRINGBORO RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1674
Mailing Address - Country:US
Mailing Address - Phone:937-297-8999
Mailing Address - Fax:937-298-9673
Practice Address - Street 1:2912 SPRINGBORO RD
Practice Address - Street 2:SUITE 201
Practice Address - City:MORAINE
Practice Address - State:OH
Practice Address - Zip Code:45439-1674
Practice Address - Country:US
Practice Address - Phone:937-396-8137
Practice Address - Fax:937-297-4868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-26
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2380294Medicaid
OH2380294Medicaid