Basic Information
| Provider Information | |||||||||
| NPI: | 1407858871 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SPFLD URB EMERGENCY PHYSICIANS INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SPFLD URB EMERGENCY PHYSICIANS INC/MERCY URBANA | ||||||||
| 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: | 904 SCIOTO ST | ||||||||
| Address2: | |||||||||
| City: | URBANA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430782226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9376535231 | ||||||||
| FaxNumber: | 9376537551 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2005 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
| 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 | 1371641 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000300375 | 01 | OH | GROUP PROVIDER NUMBER | OTHER | 202821901 | 01 | OH | DEPARTMENT OF LABOR GRP# | OTHER | 2418244 | 05 | OH | MEDICAID | 203424 | 01 | OH | EEOICP GRP PROVIDER # | OTHER | C35743 | 01 | OH | HUMANA GRP PROVIDER # | OTHER | 020407300 | 01 | OH | FEDERAL BLACK LUNG GRP# | OTHER |