Basic Information
| Provider Information | |||||||||
| NPI: | 1760768089 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREENE MEMORIAL HOSPITAL SERVICES, INC | ||||||||
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| OtherOrganizationName: | CEDARVILLE FAMILY PRACTICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2110 LEITER RD | ||||||||
| Address2: | |||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453423660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373844838 | ||||||||
| FaxNumber: | 9373844845 | ||||||||
| Practice Location | |||||||||
| Address1: | 29 KYLE DR | ||||||||
| Address2: | |||||||||
| City: | CEDARVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453149580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377662611 | ||||||||
| FaxNumber: | 9377665558 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2011 | ||||||||
| LastUpdateDate: | 11/01/2011 | ||||||||
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| AuthorizedOfficialLastName: | HAIBACH | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR BUSINESS DEVELOPMENT | ||||||||
| AuthorizedOfficialTelephone: | 9375583222 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GREENE MEMORIAL HOSPITAL SERVICES, INC | ||||||||
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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 | 2639630 | 05 | OH | MEDICAID |