Basic Information
| Provider Information | |||||||||
| NPI: | 1730174087 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOSPITALIST SERVICES MEDICAL GROUP OF HAMILTON, INC. | ||||||||
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| OtherOrganizationName: | HOSPITALIST SERVICES MEDICAL GROUP OF HAMILTON, INC./FT. HAMILTON HOSP | ||||||||
| 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: | 630 EATON AVE | ||||||||
| Address2: | |||||||||
| City: | HAMILTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450132767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138672000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2005 | ||||||||
| 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 | 1429528 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2482620 | 05 | OH | MEDICAID | DB6528 | 01 | OH | GROUP RRMEDICARE NUMBER | OTHER | 203436 | 01 | OH | EEOICP GRP PROVIDER # | OTHER |