=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710314901
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEAVERCREEK FAMILY HEALTH CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2013
-----------------------------------------------------
Last Update Date | 02/05/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2365 LAKEVIEW DR SUITE C
-----------------------------------------------------
City | BEAVERCREEK
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45431-4600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-477-3460
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2365 LAKEVIEW DR SUITE C
-----------------------------------------------------
City | BEAVERCREEK
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45431-4600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-477-3460
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. PHILIP S WHITECAR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 937-477-2460
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------