Basic Information
| Provider Information | |||||||||
| NPI: | 1932528882 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | FOREMAN | ||||||||
| FirstName: | THERESA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3131 NEWMARK DR STE 220 | ||||||||
| Address2: | |||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453425400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374364658 | ||||||||
| FaxNumber: | 9374364984 | ||||||||
| Practice Location | |||||||||
| Address1: | 3535 SOUTHERN BLVD | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454291221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373958166 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2014 | ||||||||
| LastUpdateDate: | 05/07/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 35.130755 | OH | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0224022 | 05 | OH | MEDICAID |