1154328425 NPI number — ELECTRO DIAGNOSTIC MEDICINE AND REHABILITATION SPECIALISTS LLC

Table of content: (NPI 1154328425)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154328425 NPI number — ELECTRO DIAGNOSTIC MEDICINE AND REHABILITATION SPECIALISTS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELECTRO DIAGNOSTIC MEDICINE AND REHABILITATION SPECIALISTS 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:
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NPI Number Information

NPI Number:
1154328425
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/24/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10547 MONTGOMERY RD STE 700
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTGOMERY
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45242-4418
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-489-8000
Provider Business Mailing Address Fax Number:
513-247-2782

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10547 MONTGOMERY RD
Provider Second Line Business Practice Location Address:
STE 700
Provider Business Practice Location Address City Name:
MONTGOMERY
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45242-4418
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-489-8000
Provider Business Practice Location Address Fax Number:
513-247-2782
Provider Enumeration Date:
07/01/2005

Additional Information

Authorized Official

Authorized Official Last Name:
KILGORE
Authorized Official First Name:
BRANDY
Authorized Official Middle Name:
Authorized Official Title or Position:
EMARS OFFICE MANAGER
Authorized Official Telephone Number:
513-489-8000

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0582669 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 65938516 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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