Basic Information
| Provider Information | |||||||||
| NPI: | 1962883587 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | ADDISON | ||||||||
| FirstName: | AUGUSTINA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3170 KETTERING BLVD BLDG B3 | ||||||||
| Address2: | |||||||||
| City: | MORAINE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454391924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9379913188 | ||||||||
| FaxNumber: | 9372239811 | ||||||||
| Practice Location | |||||||||
| Address1: | 3130 N COUNTY ROAD 25A STE 205 | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453731337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373351660 | ||||||||
| FaxNumber: | 9374404020 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2015 | ||||||||
| LastUpdateDate: | 10/16/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | MT209133 | PA | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 35.140195 | OH | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 0413049 | 05 | OH | MEDICAID |