Healthcare Provider Details

I. General information

NPI: 1730378621
Provider Name (Legal Business Name): MIAMI VALLEY COLON AND RECTAL SURGEONS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2007
Last Update Date: 10/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3080 ACKERMAN BLVD SUITE 110
DAYTON OH
45429-3561
US

IV. Provider business mailing address

3080 ACKERMAN BLVD SUITE 110
DAYTON OH
45429-3561
US

V. Phone/Fax

Practice location:
  • Phone: 937-293-6188
  • Fax: 937-293-6196
Mailing address:
  • Phone: 937-293-6188
  • Fax: 937-293-6196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number35065836
License Number StateOH

VIII. Authorized Official

Name: MRS. KAREN A CONOVER
Title or Position: BUSINESS MANAGER
Credential:
Phone: 937-293-6188