MEDICARE: PRIMECARE PHYSICIANS OF WEST CENTRAL OHIO, INC

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	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1609084375
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIMECARE PHYSICIANS OF WEST CENTRAL OHIO, INC

Provider Business Mailing Address
First Line	:	1205 FAIRINGTON DR
Second Line	:
City	:	SIDNEY
State	:	OH
Zip	:	45365-8144
Country	:	US
Telephone Number	:	937-492-8431
Fax Number	:	937-498-5126

Provider Business Practice Location Address
First Line	:	1205 FAIRINGTON DR
Second Line	:
City	:	SIDNEY
State	:	OH
Zip	:	45365-8144
Country	:	US
Telephone Number	:	937-492-8431
Fax Number	:	937-498-5126

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	JEANIE BOSSLET
Credential	:
Telephone Number	:	937-492-8431

Provider Enumeration Date	:	05/18/2007
Last Update Date	:	10/24/2011

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