1568576205 NPI number — GARY J CONNER MD

Table of content: GARY J CONNER MD (NPI 1568576205)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568576205 NPI number — GARY J CONNER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CONNER
Provider First Name:
GARY
Provider Middle Name:
J
Provider Name Prefix Text:
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:
1568576205
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/23/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5100 SPRINGFIELD ST
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
DAYTON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45431-1261
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-259-9900
Provider Business Mailing Address Fax Number:
937-259-9999

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 WYOMING ST
Provider Second Line Business Practice Location Address:
SUITE 4130
Provider Business Practice Location Address City Name:
DAYTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45409-2722
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-208-6810
Provider Business Practice Location Address Fax Number:
937-222-7255
Provider Enumeration Date:
08/19/2006

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: 207V00000X , with the licence number:  MD024974E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207VG0400X , with the licence number: 20076 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 001403635-0015 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 19587 . This is a "ACOG" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 512G700003 . This is a "UP MCARE PTAN" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: P00707005 . This is a "RAILROAD PTAN" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 03479303 . This is a "MEDICAID UP MS MC" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: C30324 . This is a "UPIN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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