Basic Information
| Provider Information | |||||||||
| NPI: | 1114920329 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WRIGHT STATE PHYSICIANS INC | ||||||||
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| OtherOrganizationName: | UNIVERISTY MEDICAL SERVICES ASSOC. INC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 725 UNIVERSITY BLVD | ||||||||
| Address2: | |||||||||
| City: | FAIRBORN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453240000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372457100 | ||||||||
| FaxNumber: | 9372457999 | ||||||||
| Practice Location | |||||||||
| Address1: | 725 UNIVERSITY BLVD | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454350001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372457100 | ||||||||
| FaxNumber: | 9372457999 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2005 | ||||||||
| LastUpdateDate: | 12/03/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PAUL | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
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| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 9372457125 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | 207QG0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RE0101X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207RI0200X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 207RR0500X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207VX0201X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology | 207X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0206X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology | 208200000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery | 2084N0400X | 821388 | OH | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1205197985 | 01 | OH | SUBPART NPI DME MOB | OTHER | 0914443 | 05 | OH | MEDICAID | 1427299841 | 01 | NCS SUBPARTSURG ONC | OTHER | 3610562 | 01 | MEDICARE PTAN ASC | OTHER | 1306087515 | 01 | NCS SUBPART PLSTC SURG 6257 | OTHER | 1417133380 | 01 | ORTHO DME SUBGROUP | OTHER | 1649447582 | 01 | ASC SUBGROUP | OTHER | 0654700009 | 01 | NSC SUITE 5253 | OTHER | 1215178421 | 01 | NSC SUBPART VASC SURG | OTHER | 1295977254 | 01 | ASC DME NPI | OTHER | 10654700002 | 01 | OH | MEDICARE DME PTAN | OTHER | 1316188147 | 01 | SURGERY DME SUBGROUP | OTHER | 821388 | 01 | OH | BUSINESS LICENSE | OTHER |