1417133380 NPI number — WRIGHT STATE PHYSICIANS INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417133380 NPI number — WRIGHT STATE PHYSICIANS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WRIGHT STATE PHYSICIANS INC
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:
6
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:
1417133380
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/12/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
725 UNIVERSITY BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAYTON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45435-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-245-7100
Provider Business Mailing Address Fax Number:
937-245-7999

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30 E APPLE ST
Provider Second Line Business Practice Location Address:
STE 2200
Provider Business Practice Location Address City Name:
DAYTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45409-2939
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-208-2091
Provider Business Practice Location Address Fax Number:
937-208-6141
Provider Enumeration Date:
01/10/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MARCO
Authorized Official First Name:
ALAN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
937-245-7100

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  821388 , 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: 1114920329 . This is a "PARENT COMPANY NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0914443 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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