Provider Demographics
NPI:1831292218
Name:SHAWN S OSTERHOLT MD LLC
Entity Type:Organization
Organization Name:SHAWN S OSTERHOLT MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:S
Authorized Official - Last Name:OSTERHOLT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-399-7100
Mailing Address - Street 1:1108 VESTER AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503
Mailing Address - Country:US
Mailing Address - Phone:937-399-7100
Mailing Address - Fax:937-399-7355
Practice Address - Street 1:1108 VESTER AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503
Practice Address - Country:US
Practice Address - Phone:937-399-7100
Practice Address - Fax:937-399-7355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350762270207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2470062Medicaid
I04347Medicare UPIN
OH2470062Medicaid