Healthcare Provider Details

I. General information

NPI: 1992960157
Provider Name (Legal Business Name): PRADEESH M. GEORGE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2008
Last Update Date: 09/16/2020
Certification Date: 09/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3130 N COUNTY ROAD 25A STE 214
TROY OH
45373-1337
US

IV. Provider business mailing address

3170 KETTERING BLVD BLDG B3
MORAINE OH
45439-1924
US

V. Phone/Fax

Practice location:
  • Phone: 937-332-8777
  • Fax: 937-332-8773
Mailing address:
  • Phone: 937-991-3188
  • Fax: 937-223-9811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number34.010935
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number34.010935
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number34.010935
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number02004534A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: