Healthcare Provider Details

I. General information

NPI: 1407472004
Provider Name (Legal Business Name): PHYSICAL MEDICINE CENTER OF ST ELIZABETH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2020
Last Update Date: 06/19/2020
Certification Date: 06/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ELIZABETH PL STE 1100B
DAYTON OH
45417-3445
US

IV. Provider business mailing address

1 ELIZABETH PL STE 1100B
DAYTON OH
45417-3445
US

V. Phone/Fax

Practice location:
  • Phone: 937-813-7666
  • Fax: 937-813-7667
Mailing address:
  • Phone: 937-813-7666
  • Fax: 937-813-7667

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateNULL

VIII. Authorized Official

Name: FUAD AMER
Title or Position: OWNER
Credential: DC
Phone: 513-213-0919