Basic Information
Provider Information | |||||||||
NPI: | 1487921292 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GREENE MEMORIAL HOSPITAL SERVICES, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MANOJ R DESAI, MD | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2110 LEITER RD | ||||||||
Address2: |   | ||||||||
City: | MIAMISBURG | ||||||||
State: | OH | ||||||||
PostalCode: | 453423660 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9373844838 | ||||||||
FaxNumber: | 9373844845 | ||||||||
Practice Location | |||||||||
Address1: | 717 W XENIA DR | ||||||||
Address2: |   | ||||||||
City: | FAIRBORN | ||||||||
State: | OH | ||||||||
PostalCode: | 453244930 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9378784531 | ||||||||
FaxNumber: | 9378784070 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/22/2011 | ||||||||
LastUpdateDate: | 11/22/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HAIBACH | ||||||||
AuthorizedOfficialFirstName: | DANIEL | ||||||||
AuthorizedOfficialMiddleName: | D | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR BUSINESS DEVELOPMENT | ||||||||
AuthorizedOfficialTelephone: | 9375583222 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | GREENE MEMORIAL HOSPITAL SERVICES, INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 2639630 | 05 | OH |   | MEDICAID |