Provider Demographics
NPI:1669442646
Name:EAST SURGICAL GROUP INC
Entity Type:Organization
Organization Name:EAST SURGICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:R
Authorized Official - Last Name:WELDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-393-9494
Mailing Address - Street 1:BOX 839
Mailing Address - Street 2:1404 NORTH HIGH ST
Mailing Address - City:HILLSBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45133
Mailing Address - Country:US
Mailing Address - Phone:937-393-9494
Mailing Address - Fax:937-393-8471
Practice Address - Street 1:1404 NORTH HIGH ST
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OH
Practice Address - Zip Code:45133
Practice Address - Country:US
Practice Address - Phone:937-393-9494
Practice Address - Fax:937-393-8471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35050873208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0560834Medicaid
WE0550362Medicare ID - Type Unspecified
OH0560834Medicaid