Basic Information
| Provider Information | |||||||||
| NPI: | 1609056548 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAYETTE COUNTY 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: | 9376194373 | ||||||||
| Practice Location | |||||||||
| Address1: | 1430 COLUMBUS AVE | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON COURT HOUSE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 431601703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403332862 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2007 | ||||||||
| LastUpdateDate: | 05/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | COLE | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| 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 | 1723542 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2810604 | 05 | OH | MEDICAID | 000000541946 | 01 | OH | ANTHEM/BCBS | OTHER |