Provider Demographics
NPI:1821373945
Name:PROVIDENCE MEDICAL GROUP INC
Entity Type:Organization
Organization Name:PROVIDENCE MEDICAL GROUP INC
Other - Org Name:PROVIDENCE SURGERY CENTER@ CORNERSTONE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATIONS OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:BECKER
Authorized Official - Suffix:
Authorized Official - Credentials:COO
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:
Practice Address - Street 1:7756 WASHINGTON VILLAGE DR
Practice Address - Street 2:SUITE 125
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-3999
Practice Address - Country:US
Practice Address - Phone:937-297-8999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-10-20
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH005030207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2380294Medicaid
OHPR9326251Medicare PIN