Healthcare Provider Details

I. General information

NPI: 1558389692
Provider Name (Legal Business Name): MARTIN P AMBROSE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 03/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3095 DAYTON XENIA RD STE 900
BEAVERCREEK OH
45434-4305
US

IV. Provider business mailing address

8881 NORTH MAIN STREET
DAYTON OH
45415-1333
US

V. Phone/Fax

Practice location:
  • Phone: 937-458-4010
  • Fax: 937-458-4019
Mailing address:
  • Phone: 937-832-5292
  • Fax: 937-832-7505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number060025
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number35.060025
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number060025
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: