Provider Demographics
NPI:1316115900
Name:E G SYBRANDY-NICELY, DPM
Entity type:Organization
Organization Name:E G SYBRANDY-NICELY, DPM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:G
Authorized Official - Last Name:NICELY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:937-293-8448
Mailing Address - Street 1:1001 SHROYER RD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45419-3635
Mailing Address - Country:US
Mailing Address - Phone:937-293-8448
Mailing Address - Fax:937-293-8448
Practice Address - Street 1:1001 SHROYER RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45419-3635
Practice Address - Country:US
Practice Address - Phone:937-293-8448
Practice Address - Fax:937-293-8448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-15
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36-002389332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0969831Medicaid
OH1235138496OtherNPI-INDIVIDUAL
OHU48100Medicare UPIN
OH0969831Medicaid