MEDICARE: P3 MEDICAL GROUP, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician

General Provider Information

NPI Number	:	1184938029
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	P3 MEDICAL GROUP, LLC

Provider Business Mailing Address
First Line	:	325 N MAIN ST
Second Line	:	SUITE 206
City	:	SPRINGBORO
State	:	OH
Zip	:	45066-8005
Country	:	US
Telephone Number	:	937-619-0407
Fax Number	:	937-619-0408

Provider Business Practice Location Address
First Line	:	325 N MAIN ST
Second Line	:	SUITE 206
City	:	SPRINGBORO
State	:	OH
Zip	:	45066-8005
Country	:	US
Telephone Number	:	937-619-0407
Fax Number	:	937-619-0408

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	MR. MICHAEL MCQUINN
Credential	:
Telephone Number	:	937-619-0407

Provider Enumeration Date	:	08/03/2010
Last Update Date	:	08/18/2010

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