Provider Demographics
NPI:1912261744
Name:PROVIDENCE HEALTH PARTNERS
Entity type:Organization
Organization Name:PROVIDENCE HEALTH PARTNERS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BOARD PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:HUBACH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:937-849-1363
Mailing Address - Street 1:2912 SPRINGBORO RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1674
Mailing Address - Country:US
Mailing Address - Phone:937-297-8999
Mailing Address - Fax:937-298-9673
Practice Address - Street 1:2912 SPRINGBORO RD
Practice Address - Street 2:SUITE 201
Practice Address - City:MORAINE
Practice Address - State:OH
Practice Address - Zip Code:45439-1674
Practice Address - Country:US
Practice Address - Phone:937-297-8999
Practice Address - Fax:937-298-9673
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HEALTH PARTNERS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-06-26
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1100XAmbulatory Health Care FacilitiesClinic/CenterResearch