=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184626384
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GARY J FISHBEIN MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2005
-----------------------------------------------------
Last Update Date | 03/22/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2350 MIAMI VALLEY DR STE 310
-----------------------------------------------------
City | CENTERVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45459-4778
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-277-4274
-----------------------------------------------------
Fax | 937-277-8476
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3170 KETTERING BLVD STE 300
-----------------------------------------------------
City | MORAINE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45439-1924
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-991-3188
-----------------------------------------------------
Fax | 937-223-9811
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | 35-06-5086
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RI0011X
-----------------------------------------------------
Taxonomy Name | Interventional Cardiology Physician
-----------------------------------------------------
License Number | 35-06-5086
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------