Basic Information
Provider Information | |||||||||
NPI: | 1093997934 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ADENA HEATLH SYSTEM | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | FAMILY MEDICINE OF CHILLICOTHE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 272 HOSPITAL RD | ||||||||
Address2: | SUITE 3 | ||||||||
City: | CHILLICOTHE | ||||||||
State: | OH | ||||||||
PostalCode: | 456019031 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7407794460 | ||||||||
FaxNumber: | 7407794257 | ||||||||
Practice Location | |||||||||
Address1: | 626 CENTRAL CTR | ||||||||
Address2: |   | ||||||||
City: | CHILLICOTHE | ||||||||
State: | OH | ||||||||
PostalCode: | 456012248 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7407794060 | ||||||||
FaxNumber: | 7407794069 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/03/2007 | ||||||||
LastUpdateDate: | 06/04/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ROSENBERGER | ||||||||
AuthorizedOfficialFirstName: | ROBERT | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 7407797582 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 1475685 | 05 | OH |   | MEDICAID |