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General NPI Number Information
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NPI Number | 1831300862
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Entity Type | Organization
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Legal Business Name | WATERSTREET FAMILY PRACTICE, INC.
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Dates
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Enumeration Date | 05/24/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1162 N MONROE DR
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City | XENIA
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State | OH
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Zip | 45385-1620
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Country | US
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Telephone | 937-374-6450
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Fax | 937-374-6455
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Provider Business Mailing Address
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Address Line | 1162 N MONROE DR
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City | XENIA
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State | OH
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Zip | 45385-1620
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Country | US
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Telephone | 937-374-6450
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Fax | 937-374-6455
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Authorized Official
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Title or Position | PHYSICIAN
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Name | PENNY SUE HOGAN
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Credential | MD
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Telephone | 937-374-6450
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QS0010X
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Taxonomy Name | Sports Medicine (Family Medicine) Physician
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License Number | 35071125H
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License Number State | OH
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