Basic Information
| Provider Information | |||||||||
| NPI: | 1467690149 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SIDNEY EMERGENCY PHYSICIANS, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4750 HEMPSTEAD STATION DR | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454295164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008750136 | ||||||||
| FaxNumber: | 9376194150 | ||||||||
| Practice Location | |||||||||
| Address1: | 915 MICHIGAN ST | ||||||||
| Address2: | |||||||||
| City: | SIDNEY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453652401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374982311 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2009 | ||||||||
| LastUpdateDate: | 10/07/2011 | ||||||||
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| AuthorizedOfficialLastName: | COLE | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8007263627 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000604959 | 01 | OH | ANTHEM BCBS | OTHER | 2938585 | 05 | OH | MEDICAID |