MEDICARE: E G SYBRANDY-NICELY, DPM

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	332B00000X	Durable Medical Equipment & Medical Supplies	36-002389	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	1235138496	OTHER	OH	NPI-INDIVIDUAL

General Provider Information

NPI Number	:	1316115900
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	E G SYBRANDY-NICELY, DPM

Provider Business Mailing Address
First Line	:	1001 SHROYER RD
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45419-3635
Country	:	US
Telephone Number	:	937-293-8448
Fax Number	:	937-293-8448

Provider Business Practice Location Address
First Line	:	1001 SHROYER RD
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45419-3635
Country	:	US
Telephone Number	:	937-293-8448
Fax Number	:	937-293-8448

Authorized Official
Title or Position	:	OWNER/PODIATRIST
Name	:	DR. LISA G NICELY
Credential	:	DPM
Telephone Number	:	937-293-8448

Provider Enumeration Date	:	02/15/2008
Last Update Date	:	02/15/2008

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