Provider Demographics
NPI:1831300862
Name:WATERSTREET FAMILY PRACTICE, INC.
Entity Type:Organization
Organization Name:WATERSTREET FAMILY PRACTICE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:HOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-374-6450
Mailing Address - Street 1:1162 N MONROE DR
Mailing Address - Street 2:
Mailing Address - City:XENIA
Mailing Address - State:OH
Mailing Address - Zip Code:45385-1620
Mailing Address - Country:US
Mailing Address - Phone:937-374-6450
Mailing Address - Fax:937-374-6455
Practice Address - Street 1:1162 N MONROE DR
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-1620
Practice Address - Country:US
Practice Address - Phone:937-374-6450
Practice Address - Fax:937-374-6455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35071125H207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2150032Medicaid
OHG81673Medicare UPIN
OH2150032Medicaid