Basic Information
| Provider Information | |||||||||
| NPI: | 1285629113 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HOSPITALIST SERVICES MEDICAL GROUP OF SPRINGFIELD, INC | ||||||||
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| OtherOrganizationName: | HOSPITALIST SERVICES MEDICAL GROUP OF SPRINGFIELD, INC./MERCY SPRINGFI | ||||||||
| 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: | 1343 N FOUNTAIN BLVD | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 455041422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373905000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2005 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | KOLODZIK | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 8007263627 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 1430089 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 203435 | 01 | OH | EEOICP GROUP PROVIDER # | OTHER | 000000334883 | 01 | OH | ANTHEM | OTHER | 2482648 | 05 | OH | MEDICAID |