=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326749136
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JAY AMBE MA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2023
-----------------------------------------------------
Last Update Date | 03/17/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9316 PARAGON MILLS LN
-----------------------------------------------------
City | CENTERVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45458-4184
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-304-8551
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9316 PARAGON MILLS LN
-----------------------------------------------------
City | CENTERVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45458-4184
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | KAMINI PATEL
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 937-304-8551
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------