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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