Basic Information
| Provider Information | |||||||||
| NPI: | 1780772426 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIAMISBURG FAMILY PRACTICE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 BYERS RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9378662494 | ||||||||
| FaxNumber: | 9378668494 | ||||||||
| Practice Location | |||||||||
| Address1: | 415 BYERS RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9378662494 | ||||||||
| FaxNumber: | 9378668494 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | TURNER | ||||||||
| AuthorizedOfficialFirstName: | LAGUITA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | ASST OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9378662494 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0827752 | 05 | OH | MEDICAID |