Basic Information
| Provider Information | |||||||||
| NPI: | 1881886984 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LEWISBURG FAMILY PRACTICE, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 578 | ||||||||
| Address2: | |||||||||
| City: | LEWISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453380578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9379622618 | ||||||||
| FaxNumber: | 9379624971 | ||||||||
| Practice Location | |||||||||
| Address1: | 405 W GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454057538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373956665 | ||||||||
| FaxNumber: | 9373956668 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2007 | ||||||||
| LastUpdateDate: | 04/04/2018 | ||||||||
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| AuthorizedOfficialLastName: | BOGGS | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | TODD | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9379622618 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35067136 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0169384 | 05 | OH | MEDICAID |