Organization
PROVIDENCE MEDICAL GROUP
Active
Organization
PROVIDENCE MEDICAL GROUP
Active
Parent organization
PROVIDENCE MEDICAL GROUP
Other names
PMG LAB
Organization subpart
Yes
Provider details
NPI number
Legal business name
PROVIDENCE MEDICAL GROUP
Authorized official
SHIRLEY A PFEIFFER (CREDENTIALING COORDINATOR)
(937) 297-8999
Entity
Organization
Contact information
Practice address
2912 SPRINGBORO W, SUITE 203, MORAINE, OH 45439-1674
(937) 297-8999
(937) 298-9673
Mailing address
2912 SPRINGBORO W, SUITE 203, MORAINE, OH 45439-1674
(937) 297-8999
(937) 298-9673
Taxonomy
Speciality
Code
Description
License number
State
291U00000X
Clinical Medical Laboratory
Primary
016189
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
2380294
—
OH
Enumeration date
05/03/2008
Last updated
11/26/2014
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