MEDICARE: OHIO PODIATRIC PHYSICIANS AND SURGEONS GROUP, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213ES0103X	Foot & Ankle Surgery Podiatrist	36003474	OH
2	213ES0131X	Foot Surgery Podiatrist	36003474	OH
3	213EP1101X	Primary Podiatric Medicine Podiatrist	36003474	OH

General Provider Information

NPI Number	:	1043617020
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OHIO PODIATRIC PHYSICIANS AND SURGEONS GROUP, LLC

Provider Business Mailing Address
First Line	:	5925 N. MAIN ST.
Second Line	:	SUITE D
City	:	DAYTON
State	:	OH
Zip	:	45415-3142
Country	:	US
Telephone Number	:	937-426-9500
Fax Number	:	855-482-2337

Provider Business Practice Location Address
First Line	:	5925 N. MAIN ST.
Second Line	:	SUITE D
City	:	DAYTON
State	:	OH
Zip	:	45415-3142
Country	:	US
Telephone Number	:	937-426-9500
Fax Number	:	855-482-2337

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. MARIA D. GUEHL
Credential	:
Telephone Number	:	937-426-9500

Provider Enumeration Date	:	11/19/2014
Last Update Date	:	12/02/2014

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