Provider Demographics
NPI:1811304595
Name:PROVIDENCE MEDICAL GROUP
Entity type:Organization
Organization Name:PROVIDENCE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
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:937-297-4852
Practice Address - Street 1:2912 SPRINGBORO RD
Practice Address - Street 2:SUITE 201
Practice Address - City:MORAINE
Practice Address - State:OH
Practice Address - Zip Code:45439-1674
Practice Address - Country:US
Practice Address - Phone:937-297-8999
Practice Address - Fax:937-297-4852
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE PODIATRY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-07-15
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36.003657213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1285952937OtherINDIVIDUAL NPI
OH2380294Medicaid
OH0083030Medicaid
OHH198263Medicare PIN