Basic Information
| Provider Information | |||||||||
| NPI: | 1073513164 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BUCYRUS EMERGENCY PHYSICIANS INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BUCYRUS EMERGENCY PHYSICIANS/BUCYRUS COMMUNITY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4750 HEMPSTEAD STATION DR | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454295164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008750136 | ||||||||
| FaxNumber: | 9376194231 | ||||||||
| Practice Location | |||||||||
| Address1: | 629 N SANDUSKY AVE | ||||||||
| Address2: | |||||||||
| City: | BUCYRUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448201821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195624677 | ||||||||
| FaxNumber: | 4195620987 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2005 | ||||||||
| LastUpdateDate: | 03/08/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COLE | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8007263627 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 1402127 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000316687 | 01 | OH | BC/BS GRP PROVIDER NUMBER | OTHER | 2458120 | 05 | OH | MEDICAID |