MEDICARE: PROVIDENCE MEDICAL GROUP

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	133V00000X	Registered Dietitian		OH
2	163WD0400X	Diabetes Educator Registered Nurse		OH
3	207V00000X	Obstetrics & Gynecology Physician
4	208000000X	Pediatrics Physician
5	208600000X	Surgery Physician
6	2088F0040X	Urogynecology and Reconstructive Pelvic Surgery (Urology) Physician
7	208C00000X	Colon & Rectal Surgery Physician
8	208D00000X	General Practice Physician
9	291U00000X	Clinical Medical Laboratory
10	363AM0700X	Medical Physician Assistant
11	363L00000X	Nurse Practitioner	1313008	OH
12	363LA2100X	Acute Care Nurse Practitioner
13	363LA2200X	Adult Health Nurse Practitioner
14	363LP0200X	Pediatric Nurse Practitioner
15	207Q00000X	Family Medicine Physician

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

General Provider Information

NPI Number	:	1972533149
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVIDENCE MEDICAL GROUP

Provider Business Mailing Address
First Line	:	2912 SPRINGBORO RD W
Second Line	:	SUITE 201
City	:	DAYTON
State	:	OH
Zip	:	45439-1674
Country	:	US
Telephone Number	:	937-297-8999
Fax Number	:	937-297-4852

Provider Business Practice Location Address
First Line	:	2912 SPRINGBORO RD W
Second Line	:	SUITE 201
City	:	DAYTON
State	:	OH
Zip	:	45439-1674
Country	:	US
Telephone Number	:	937-297-8999
Fax Number	:	937-297-4852

Authorized Official
Title or Position	:	CHIEF OPERATING OFFICER
Name	:	MRS. SUSAN J BECKER
Credential	:	COO
Telephone Number	:	937-297-8999

Provider Enumeration Date	:	07/04/2006
Last Update Date	:	10/19/2022

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2912 SPRINGBORO W , SUITE 201
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1982702213 — PAULA A KIMPTON NP-C
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1699831693 — DR. TERREN BURGESS KOLES M.D.
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Practice Location Address:

2912 SPRINGBORO RD WEST , SUITE 201
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1992976393 — KRISTINA A ROST-MANGAN MS, RN, CNP
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Directions to “PROVIDENCE MEDICAL GROUP ” Practice Location

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