1043617020 NPI number — OHIO PODIATRIC PHYSICIANS AND SURGEONS GROUP, LLC

Table of content: (NPI 1043617020)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043617020 NPI number — OHIO PODIATRIC PHYSICIANS AND SURGEONS GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OHIO PODIATRIC PHYSICIANS AND SURGEONS GROUP, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043617020
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/02/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5925 N. MAIN ST.
Provider Second Line Business Mailing Address:
SUITE D
Provider Business Mailing Address City Name:
DAYTON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45415-3142
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-426-9500
Provider Business Mailing Address Fax Number:
855-482-2337

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5925 N. MAIN ST.
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
DAYTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45415-3142
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-426-9500
Provider Business Practice Location Address Fax Number:
855-482-2337
Provider Enumeration Date:
11/19/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GUEHL
Authorized Official First Name:
MARIA
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
937-426-9500

Provider Taxonomy Codes

  • Taxonomy code: 213EP1101X , with the licence number:  36003474 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 213ES0103X , with the licence number: 36003474 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ES0131X , with the licence number: 36003474 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)