Basic Information
| Provider Information | |||||||||
| NPI: | 1740453984 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPRINGBORO FAMILY MEDICINE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 SYCAMORE CREEK DRIVE | ||||||||
| Address2: | |||||||||
| City: | SPRINGBORO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377484211 | ||||||||
| FaxNumber: | 9377483566 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 SYCAMORE CREEK DRIVE | ||||||||
| Address2: | |||||||||
| City: | SPRINGBORO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377484211 | ||||||||
| FaxNumber: | 9377483566 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2008 | ||||||||
| LastUpdateDate: | 04/09/2008 | ||||||||
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| AuthorizedOfficialLastName: | GRAU | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | BETH | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 9377484211 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 34008059M | OH | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2519162 | 05 | OH | MEDICAID |