Basic Information
Provider Information | |||||||||
NPI: | 1811151079 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CONCENTRA HEALTH SERVICES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5080 SPECTRUM DR | ||||||||
Address2: | SUITE 1200 WEST TOWER | ||||||||
City: | ADDISON | ||||||||
State: | TX | ||||||||
PostalCode: | 750014648 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8002323550 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 228 TROY ST | ||||||||
Address2: |   | ||||||||
City: | DAYTON | ||||||||
State: | OH | ||||||||
PostalCode: | 454041831 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9372288132 | ||||||||
FaxNumber: | 9372287185 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/16/2008 | ||||||||
LastUpdateDate: | 02/05/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NEWTON | ||||||||
AuthorizedOfficialFirstName: | KEITH | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT / CEO | ||||||||
AuthorizedOfficialTelephone: | 9723648106 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy | 261QX0100X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Occupational Medicine | 261QH0100X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Health Service |
No ID Information.