1336106111 NPI number — DR. ROGELIO VIRGILIO B AMISOLA MD

Table of content: DR. ROGELIO VIRGILIO B AMISOLA MD (NPI 1336106111)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336106111 NPI number — DR. ROGELIO VIRGILIO B AMISOLA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AMISOLA
Provider First Name:
ROGELIO
Provider Middle Name:
VIRGILIO B
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1336106111
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/17/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 933432
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEVELAND
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44193-0039
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-641-5072
Provider Business Mailing Address Fax Number:
937-641-6129

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1425 N FAIRFIELD RD.
Provider Second Line Business Practice Location Address:
120
Provider Business Practice Location Address City Name:
BEAVERCREEK
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45432-4543
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-320-8888
Provider Business Practice Location Address Fax Number:
937-320-3848
Provider Enumeration Date:
04/27/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2080A0000X , with the licence number:  35-08-4304 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 35-08-4304 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2507246 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".