MEDICARE: DOUGLAS EULBERG PA-C

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	363AM0700X	Medical Physician Assistant	50-000152	OH

General Provider Information

NPI Number	:	1558353904
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOUGLAS EULBERG PA-C

Provider Business Mailing Address
First Line	:	415 COLONIAL DR
Second Line	:
City	:	BEAVERCREEK
State	:	OH
Zip	:	45434-5807
Country	:	US
Telephone Number	:	937-427-8018
Fax Number	:	937-424-2581

Provider Business Practice Location Address
First Line	:	3075 GOVERNORS PLACE BLVD
Second Line	:	SUITE 120
City	:	DAYTON
State	:	OH
Zip	:	45409-1323
Country	:	US
Telephone Number	:	937-424-2580
Fax Number	:	937-424-2581

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2005
Last Update Date	:	06/30/2010

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