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Organization
PROVIDENCE MEDICAL GROUP
Active
Organization
PROVIDENCE MEDICAL GROUP
Active
Parent organization
PROVIDENCE PODIATRY
Organization subpart
Yes
Provider details
NPI number
Legal business name
PROVIDENCE PODIATRY
Authorized official
SUSAN BECKER COO (CHIEF OPERATING OFFICER)
(937) 297-8999
Entity
Organization
Contact information
Practice address
2912 SPRINGBORO RD, SUITE 201, MORAINE, OH 45439-1674
(937) 297-8999
(937) 297-4852
Mailing address
2912 SPRINGBORO RD, SUITE 201, MORAINE, OH 45439-1674
(937) 297-8999
(937) 297-4852
Taxonomy
Speciality
Code
Description
License number
State
213E00000X
Podiatrist
Primary
36.003657
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0083030
—
OH
01
—
1285952937
INDIVIDUAL NPI
OH
05
—
2380294
—
OH
Enumeration date
07/15/2014
Last updated
10/28/2014
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