Organization
PROVIDENCE MEDICAL GROUP INC
Active
Parent organization
PROVIDENCE MEDICAL GROUP
Other names
Providence Surgery Center@ Cornerstone
Organization subpart
Yes
Provider details
NPI number
Legal business name
PROVIDENCE MEDICAL GROUP
Authorized official
MRS. SUSAN J BECKER COO (CHIEF OPERATIONS OFFICER)
(937) 297-8999
Entity
Organization
Contact information
Practice address
7756 WASHINGTON VILLAGE DR, SUITE 125, CENTERVILLE, OH 45459-3999
(937) 297-8999
Mailing address
2912 SPRINGBORO RD, SUITE 201, MORAINE, OH 45439-1674
(937) 297-8999
Taxonomy
Speciality
Code
Description
License number
State
207V00000X
Obstetrics & Gynecology Physician
Primary
005030
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
2380294
—
OH
Enumeration date
10/20/2011
Last updated
10/20/2011
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