Provider Demographics
NPI:1699967513
Name:FLEAGLE INTERNAL MEDICINE LLC
Entity type:Organization
Organization Name:FLEAGLE INTERNAL MEDICINE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KURT
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:FLEAGLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-434-4775
Mailing Address - Street 1:5250 FAR HILLS AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45429
Mailing Address - Country:US
Mailing Address - Phone:937-434-4775
Mailing Address - Fax:937-434-4779
Practice Address - Street 1:5250 FAR HILLS AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45429
Practice Address - Country:US
Practice Address - Phone:937-434-4775
Practice Address - Fax:833-450-5129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-14
Last Update Date:2024-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X
OH207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9349621Medicare UPIN
OH9349621Medicare PIN