Healthcare Provider Details

I. General information

NPI: 1801076369
Provider Name (Legal Business Name): SPRINGFIELD SPINE & SPORT, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2007
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4960 MIDDLE URBANA RD
SPRINGFIELD OH
45503-6040
US

IV. Provider business mailing address

4960 MIDDLE URBANA RD
SPRINGFIELD OH
45503-6040
US

V. Phone/Fax

Practice location:
  • Phone: 937-399-8366
  • Fax: 937-399-8379
Mailing address:
  • Phone: 937-399-8366
  • Fax: 937-399-8379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number35067942
License Number StateOH

VIII. Authorized Official

Name: MRS. PAMELA K GOTHARD
Title or Position: OFFICE MANAGER
Credential:
Phone: 937-399-8366