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General NPI Number Information
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NPI Number | 1811304595
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Entity Type | Organization
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Legal Business Name | PROVIDENCE MEDICAL GROUP
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Dates
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Enumeration Date | 07/15/2014
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Last Update Date | 10/28/2014
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Provider Practice Location Address
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Address Line | 2912 SPRINGBORO RD SUITE 201
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City | MORAINE
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State | OH
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Zip | 45439-1674
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Country | US
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Telephone | 937-297-8999
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Fax | 937-297-4852
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Provider Business Mailing Address
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Address Line | 2912 SPRINGBORO RD SUITE 201
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City | MORAINE
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State | OH
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Zip | 45439-1674
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Country | US
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Telephone | 937-297-8999
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Fax | 937-297-4852
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Authorized Official
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Title or Position | CHIEF OPERATING OFFICER
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Name | SUSAN BECKER
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Credential | COO
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Telephone | 937-297-8999
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | 36.003657
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License Number State | OH
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