Basic Information
| Provider Information | |||||||||
| NPI: | 1992960157 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GEORGE | ||||||||
| FirstName: | PRADEESH | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | DO | ||||||||
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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 214 | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453731337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373328777 | ||||||||
| FaxNumber: | 9373328773 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2008 | ||||||||
| LastUpdateDate: | 09/16/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 34.010935 | OH | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0102X | 34.010935 | OH | N | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 2086S0127X | 34.010935 | OH | N | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | 2086S0127X | 02004534A | IN | Y | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0086021 | 05 | OH | MEDICAID | 201290540 | 05 | IN | MEDICAID |