Provider Demographics
NPI:1891837076
Name:SYCAMORE INTERNAL MEDICINE AND WOMEN'S WELLNESS CENTER INC
Entity Type:Organization
Organization Name:SYCAMORE INTERNAL MEDICINE AND WOMEN'S WELLNESS CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VIDA
Authorized Official - Middle Name:
Authorized Official - Last Name:FARHANGI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-866-6655
Mailing Address - Street 1:PO BOX 270
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45343-0270
Mailing Address - Country:US
Mailing Address - Phone:937-866-6655
Mailing Address - Fax:937-866-6595
Practice Address - Street 1:4000 MIAMISBURG CENTERVILLE RD
Practice Address - Street 2:SUITE 207
Practice Address - City:MIAMISBURG
Practice Address - State:OH
Practice Address - Zip Code:45342-3758
Practice Address - Country:US
Practice Address - Phone:937-866-6655
Practice Address - Fax:937-866-6595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-07-8961F207R00000X
OH35.092005207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0565421OtherCIGNA
OH2232873Medicaid
OHD-78961OtherHUMANA
OH000000578348OtherANTHEM
OH274966422004OtherMEDICAL MUTUAL OF OHIO
OH6199428002OtherCIGNA
OH2678666OtherAETNA
76-00115OtherUNITED HEALTHCARE
000000233015OtherANTHEM
OH1851390983OtherRENDERING PROVIDER NPI
OH2472827OtherUNITED HEALTHCARE
OH7028685OtherAETNA
000000233015OtherBCBS
OHDB6813OtherRAILROAD MEDICARE
OH1851374615OtherRENDERING PROVIDER
OH1851390983OtherRENDERING PROVIDER NPI
OH2232873Medicaid
OH2678666OtherAETNA
OH7028685OtherAETNA