Healthcare Provider Details

I. General information

NPI: 1669442646
Provider Name (Legal Business Name): EAST SURGICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1404 NORTH HIGH ST
HILLSBORO OH
45133
US

IV. Provider business mailing address

BOX 839 1404 NORTH HIGH ST
HILLSBORO OH
45133
US

V. Phone/Fax

Practice location:
  • Phone: 937-393-9494
  • Fax: 937-393-8471
Mailing address:
  • Phone: 937-393-9494
  • Fax: 937-393-8471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number35050873
License Number StateOH

VIII. Authorized Official

Name: LINDA R WELDER
Title or Position: PRESIDENT
Credential: MD
Phone: 937-393-9494