Provider Demographics
NPI:1760658371
Name:PROVIDENCE MEDICAL GROUP
Entity Type:Organization
Organization Name:PROVIDENCE MEDICAL GROUP
Other - Org Name:PMG LAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:PFEIFFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-297-8999
Mailing Address - Street 1:2912 SPRINGBORO W
Mailing Address - Street 2:SUITE 203
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 W
Practice Address - Street 2:SUITE 203
Practice Address - City:MORAINE
Practice Address - State:OH
Practice Address - Zip Code:45439-1674
Practice Address - Country:US
Practice Address - Phone:937-297-8999
Practice Address - Fax:937-298-9673
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-03
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH016189291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2380294Medicaid
OH2380294Medicaid