Basic Information
| Provider Information | |||||||||
| NPI: | 1720054190 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY FAMILY PHYSICIANS, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 141 HEALTH PROFESSIONS BUILDING | ||||||||
| Address2: | PO BOX 670582 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452670582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135584021 | ||||||||
| FaxNumber: | 5135583030 | ||||||||
| Practice Location | |||||||||
| Address1: | 825 W LOCUST ST | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 451772118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373833402 | ||||||||
| FaxNumber: | 9373830610 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SUSMAN | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | LOUIS | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5135584021 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2102923 | 05 | OH | MEDICAID |