1649257395 NPI number — WILLIAM ROSCOE DORSEY DO

Table of content: RAYMOND LOLLI (NPI 1124449566)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649257395 NPI number — WILLIAM ROSCOE DORSEY DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DORSEY
Provider First Name:
WILLIAM
Provider Middle Name:
ROSCOE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1649257395
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/04/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2591 MIAMISBURG CENTERVILLE RD
Provider Second Line Business Mailing Address:
STE 201
Provider Business Mailing Address City Name:
CENTERVILLE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45459-3711
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-439-5252
Provider Business Mailing Address Fax Number:
937-439-9242

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2591 MIAMISBURG CENTERVILLE RD
Provider Second Line Business Practice Location Address:
STE 201
Provider Business Practice Location Address City Name:
CENTERVILLE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45459-3711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-439-5252
Provider Business Practice Location Address Fax Number:
937-439-9242
Provider Enumeration Date:
12/23/2005

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: 207VG0400X , with the licence number:  3897 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207VX0000X , with the licence number: 3897 , 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: 0595539 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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