Basic Information
| Provider Information | |||||||||
| NPI: | 1376509026 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEVINE | ||||||||
| FirstName: | CAROL | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | P O BOX 1144 | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372599900 | ||||||||
| FaxNumber: | 9372599999 | ||||||||
| Practice Location | |||||||||
| Address1: | 3535 SALEM AVE | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372788645 | ||||||||
| FaxNumber: | 9372788579 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35069607 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2048948 | 05 | OH | MEDICAID |