Provider Demographics
NPI:1881886984
Name:LEWISBURG FAMILY PRACTICE, INC
Entity type:Organization
Organization Name:LEWISBURG FAMILY PRACTICE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:BOGGS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-962-2618
Mailing Address - Street 1:PO BOX 578
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45338-0578
Mailing Address - Country:US
Mailing Address - Phone:937-962-2618
Mailing Address - Fax:937-962-4971
Practice Address - Street 1:405 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45405-7538
Practice Address - Country:US
Practice Address - Phone:937-395-6665
Practice Address - Fax:937-395-6668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-13
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35067136207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0169384Medicaid
OH0169384Medicaid