Basic Information
| Provider Information | |||||||||
| NPI: | 1003888587 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HAMILTON ANCILLARY SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 750430 | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454750430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007422368 | ||||||||
| FaxNumber: | 9372912962 | ||||||||
| Practice Location | |||||||||
| Address1: | 3000 MACK RD | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450145335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372917850 | ||||||||
| FaxNumber: | 9372912962 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BROWN | ||||||||
| AuthorizedOfficialFirstName: | GRACE | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9372917850 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 0527139 | 05 | OH | MEDICAID |