Provider Demographics
NPI:1780065243
Name:MEDWELL, LLC
Entity type:Organization
Organization Name:MEDWELL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:E
Authorized Official - Last Name:IMBROGNO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-449-0800
Mailing Address - Street 1:1435 CINCINNATI ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45417-4614
Mailing Address - Country:US
Mailing Address - Phone:937-449-0800
Mailing Address - Fax:937-449-0881
Practice Address - Street 1:1435 CINCINNATI ST
Practice Address - Street 2:SUITE 100
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-4614
Practice Address - Country:US
Practice Address - Phone:937-449-0800
Practice Address - Fax:937-449-0881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-10
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.048194261Q00000X
OH35048194261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center