Basic Information
| Provider Information | |||||||||
| NPI: | 1154873727 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SPRINGBORO FAMILY MEDICINE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PREMIER HEALTH PARTNERS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 630 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGBORO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450667519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377484211 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 630 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGBORO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450667519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377484211 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2016 | ||||||||
| LastUpdateDate: | 11/09/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GUERRANT | ||||||||
| AuthorizedOfficialFirstName: | KELLY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9374998262 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MISS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | APRN.CNP.020120 | OH | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.