NPIMap

Organization Active NPI

Providence Medical Group

Doing business as PMG Lab

  • Clinical Medical Laboratory
  • Moraine, OH
National Provider Identifier
1760658371
Registry record updated Nov 26, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinical Medical LaboratoryTaxonomy code 291U00000X
License
016189 Issued in OH
Legal business name
PROVIDENCE MEDICAL GROUP
Doing business as
PMG Lab
Practice address
2912 Springboro W
Suite 203
Moraine, OH 45439-1674
Phone
(937) 297-8999
Fax
(937) 298-9673
NPI assigned
May 3, 2008
Last updated
Nov 26, 2014By the provider in NPPES
Organization subpart
Yes
Parent organization
PROVIDENCE MEDICAL GROUPAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Nov 26, 2014

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Shirley A Pfeiffer
Title
Credentialing Coordinator
Phone
(937) 297-8999

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical Medical Laboratory 291U00000X 016189 OH Primary

Addresses

Primary practice location

2912 Springboro W
Suite 203
Moraine, OH 45439-1674

Mailing address

2912 Springboro W
Suite 203
Moraine, OH 45439-1674
Phone (937) 297-8999

Other identifiers 1

IdentifierTypeStateIssuer
2380294MedicaidOH

Other names 1

  • PMG LAB Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OH

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20041109000071 OH Part B Supplier - Independent Clinical Laboratory 2860386349 1 other NPI on this enrollment
Practice locations: Moraine, OH

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
36D1023688Providence Medical Laboratory2912 Springboro W Ste 201, Dayton, OH 45439AccreditationMar 9, 2027

National Provider Directory

National Provider Directory
Tax ID family
Providence Medical Grou3 organizations share this tax ID, including this one
Part of
Providence Medical Grou

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

Locations

38 Woodcroft Trl
Dayton, OH 45430
Phone (937) 427-3333

8701 Troy Pike
Ste 20
Huber Heights, OH 45424
Phone (937) 233-7146

2912 Springboro W
Ste 203
Moraine, OH 45439

4353 E State Route 73
Ste 120
Waynesville, OH 45068
Phone (513) 897-0085

Practitioners & affiliated clinicians

Practitioners 23

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 23

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1209772800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1416960000000",
    "number": "1760658371",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2912 SPRINGBORO W",
            "address_2": "SUITE 203",
            "city": "MORAINE",
            "state": "OH",
            "postal_code": "454391674",
            "telephone_number": "937-297-8999",
            "fax_number": "937-298-9673"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2912 SPRINGBORO W",
            "address_2": "SUITE 203",
            "city": "MORAINE",
            "state": "OH",
            "postal_code": "454391674",
            "telephone_number": "937-297-8999",
            "fax_number": "937-298-9673"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENCE MEDICAL GROUP",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PROVIDENCE MEDICAL GROUP",
        "enumeration_date": "2008-05-03",
        "last_updated": "2014-11-26",
        "status": "A",
        "authorized_official_last_name": "PFEIFFER",
        "authorized_official_first_name": "SHIRLEY",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "CREDENTIALING COORDINATOR",
        "authorized_official_telephone_number": "937-297-8999"
    },
    "taxonomies": [
        {
            "code": "291U00000X",
            "taxonomy_group": "",
            "desc": "Clinical Medical Laboratory",
            "state": "OH",
            "license": "016189",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2380294",
            "state": "OH"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PMG LAB",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Moraine, OH

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 26, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.