Basic Information
| Provider Information | |||||||||
| NPI: | 1871548164 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SYCAMORE PRIMARY CARE GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10050 INNOVATION DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453424931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9375583208 | ||||||||
| FaxNumber: | 9375583247 | ||||||||
| Practice Location | |||||||||
| Address1: | 2115 LEITER RD | ||||||||
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| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453423659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373846842 | ||||||||
| FaxNumber: | 9373846939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 10/26/2015 | ||||||||
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| AuthorizedOfficialLastName: | KO | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | Y | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9375583208 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0227829 | 05 | OH | MEDICAID | SY9283031 | 01 | OH | MEDICARE | OTHER |