Basic Information
| Provider Information | |||||||||
| NPI: | 1215178421 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WRIGHT STATE PHYSICIANS INC | ||||||||
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| OtherOrganizationName: | WRIGHT STATE PHYSICIANS VASCULAR SURGERY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5100 SPRINGFIELD ST | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454311261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372599900 | ||||||||
| FaxNumber: | 9372599999 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 PHILADELPHIA DR | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454061840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372762642 | ||||||||
| FaxNumber: | 9372764419 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2009 | ||||||||
| LastUpdateDate: | 05/21/2009 | ||||||||
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| AuthorizedOfficialLastName: | DUNN | ||||||||
| AuthorizedOfficialFirstName: | MARGARET | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT/ CEO | ||||||||
| AuthorizedOfficialTelephone: | 9372599900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WRIGHT STATE PHYSICIANS INC | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0914443 | 05 | OH | MEDICAID | 1114920329 | 01 | PARENT LBN | OTHER |