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Organization
PROVIDENCE MEDICAL GROUP
Active
Organization
PROVIDENCE MEDICAL GROUP
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. SUSAN J BECKER COO (CHIEF OPERATING OFFICER)
(937) 297-8999
Entity
Organization
Contact information
Practice address
2912 SPRINGBORO RD W, SUITE 201, DAYTON, OH 45439-1674
(937) 297-8999
(937) 297-4852
Mailing address
2912 SPRINGBORO RD W, SUITE 201, DAYTON, OH 45439-1674
(937) 297-8999
(937) 297-4852
Taxonomy
Speciality
Code
Description
License number
State
133V00000X
Registered Dietitian
—
OH
163WD0400X
Diabetes Educator Registered Nurse
—
OH
207Q00000X
Family Medicine Physician
Primary
—
—
207V00000X
Obstetrics & Gynecology Physician
—
—
208000000X
Pediatrics Physician
—
—
208600000X
Surgery Physician
—
—
2088F0040X
Urogynecology and Reconstructive Pelvic Surgery (Urology) Physician
—
—
208C00000X
Colon & Rectal Surgery Physician
—
—
208D00000X
General Practice Physician
—
—
291U00000X
Clinical Medical Laboratory
—
—
363AM0700X
Medical Physician Assistant
—
—
363L00000X
Nurse Practitioner
1313008
OH
363LA2100X
Acute Care Nurse Practitioner
—
—
363LA2200X
Adult Health Nurse Practitioner
—
—
363LP0200X
Pediatric Nurse Practitioner
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
2380294
—
OH
Enumeration date
07/04/2006
Last updated
10/19/2022
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