1548224579 NPI number — FAIRBORN FAMILY PRACTICE ASSOC

Table of content: (NPI 1548224579)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548224579 NPI number — FAIRBORN FAMILY PRACTICE ASSOC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAIRBORN FAMILY PRACTICE ASSOC
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:
1548224579
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
850 E XENIA DRIVE
Provider Second Line Business Mailing Address:
SUITE 600
Provider Business Mailing Address City Name:
FAIRBORN
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45324-8760
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-878-8644
Provider Business Mailing Address Fax Number:
937-878-8646

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
850 E XENIA DRIVE
Provider Second Line Business Practice Location Address:
SUITE 600
Provider Business Practice Location Address City Name:
FAIRBORN
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45324-8760
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-878-8644
Provider Business Practice Location Address Fax Number:
937-878-8646
Provider Enumeration Date:
04/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PETERANGELO
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
JOSEPH
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
937-878-8644

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  34002102P , 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: 0003193 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0220513 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000005178 . This is a "ANTHEM BCBS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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