NPIMap

Organization Active NPI

Providence Medical Group

  • Family Medicine Physician
  • Dayton, OH
National Provider Identifier
1972533149
Registry record updated Oct 19, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
PROVIDENCE MEDICAL GROUP
Practice address
2912 Springboro Rd W
Suite 201
Dayton, OH 45439-1674
Phone
(937) 297-8999
Fax
(937) 297-4852
NPI assigned
Jul 4, 2006
Last updated
Oct 19, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 19, 2022

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

Authorized official

Name
Mrs. Susan J Becker, COO
Title
Chief Operating Officer
Phone
(937) 297-8999

Specialties & licenses 15

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical Medical Laboratory 291U00000X NU
Medical Physician Assistant 363AM0700X NU
Nurse Practitioner 363L00000X 1313008 OH
Acute Care Nurse Practitioner 363LA2100X NU
Adult Health Nurse Practitioner 363LA2200X NU
Pediatric Nurse Practitioner 363LP0200X NU
Registered Dietitian 133V00000X OH
Diabetes Educator Registered Nurse 163WD0400X OH
Family Medicine Physician 207Q00000X NU Primary
Obstetrics & Gynecology Physician 207V00000X NU
Pediatrics Physician 208000000X NU
Surgery Physician 208600000X NU
Colon & Rectal Surgery Physician 208C00000X NU
General Practice Physician 208D00000X NU
Urogynecology and Reconstructive Pelvic Surgery (Urology) Physician 2088F0040X NU

Addresses

Primary practice location

2912 Springboro Rd W
Suite 201
Dayton, OH 45439-1674

Mailing address

2912 Springboro Rd W
Suite 201
Dayton, OH 45439-1674
Phone (937) 297-8999

Other identifiers 1

IdentifierTypeStateIssuer
2380294MedicaidOH

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OH2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040215000006 OH Part B Supplier - Clinic/Group Practice 2860386349 Receives reassigned benefits from 51 practitioners
1 other NPI on this enrollment
Practice locations: Germantown, OH; Huber Heights, OH; Moraine, OH; Springboro, OH; Springfield, OH; Vandalia, OH; Waynesville, OH; Farmersville, OH…
O20041109000071 OH Part B Supplier - Independent Clinical Laboratory 2860386349 1 other NPI on this enrollment
This NPI is an additional NPI on the 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 2

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

National Provider Directory

National Provider Directory

Locations

4403 W Franklin St
Ste D
Bellbrook, OH 45305
Phone (937) 848-9010

1989 Miamisburg Centerville Rd
Ste 301
Dayton, OH 45459
Phone (937) 434-7353

49 E Center St
Farmersville, OH 45325
Phone (513) 696-2858

2320 Beechwood Dr
Germantown, OH 45327
Phone (937) 895-4092

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

Practitioners & affiliated clinicians

Practitioners 51

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 51

NPI Registry JSON

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

{
    "created_epoch": "1151971200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1666137600000",
    "number": "1972533149",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2912 SPRINGBORO RD W",
            "address_2": "SUITE 201",
            "city": "DAYTON",
            "state": "OH",
            "postal_code": "454391674",
            "telephone_number": "937-297-8999",
            "fax_number": "937-297-4852"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2912 SPRINGBORO RD W",
            "address_2": "SUITE 201",
            "city": "DAYTON",
            "state": "OH",
            "postal_code": "454391674",
            "telephone_number": "937-297-8999",
            "fax_number": "937-297-4852"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENCE MEDICAL GROUP",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-04",
        "last_updated": "2022-10-19",
        "certification_date": "2022-10-19",
        "status": "A",
        "authorized_official_last_name": "BECKER",
        "authorized_official_first_name": "SUSAN",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "CHIEF OPERATING OFFICER",
        "authorized_official_telephone_number": "937-297-8999",
        "authorized_official_name_prefix": "Mrs.",
        "authorized_official_credential": "COO"
    },
    "taxonomies": [
        {
            "code": "291U00000X",
            "taxonomy_group": "",
            "desc": "Clinical Medical Laboratory",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": "OH",
            "license": "1313008",
            "primary": false
        },
        {
            "code": "363LA2100X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Acute Care",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "363LA2200X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Adult Health",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "363LP0200X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Pediatrics",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "133V00000X",
            "taxonomy_group": "",
            "desc": "Dietitian, Registered",
            "state": "OH",
            "license": null,
            "primary": false
        },
        {
            "code": "163WD0400X",
            "taxonomy_group": "",
            "desc": "Registered Nurse, Diabetes Educator",
            "state": "OH",
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "207V00000X",
            "taxonomy_group": "",
            "desc": "Obstetrics & Gynecology",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "208600000X",
            "taxonomy_group": "",
            "desc": "Surgery",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "208C00000X",
            "taxonomy_group": "",
            "desc": "Colon & Rectal Surgery",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "208D00000X",
            "taxonomy_group": "",
            "desc": "General Practice",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "2088F0040X",
            "taxonomy_group": "",
            "desc": "Urology, Urogynecology and Reconstructive Pelvic Surgery",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2380294",
            "state": "OH"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Dayton, OH

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 19, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.