Basic Information
| Provider Information | |||||||||
| NPI: | 1538168083 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIAMI VALLEY CARDIOLOGISTS INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 122 WYOMING ST | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454092731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372234461 | ||||||||
| FaxNumber: | 9372241945 | ||||||||
| Practice Location | |||||||||
| Address1: | 122 WYOMING ST | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454092731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372234461 | ||||||||
| FaxNumber: | 9372241945 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WENZKE | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9372234461 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 35048670 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 0359964 | 05 | OH | MEDICAID |