Provider Demographics
NPI:1871057992
Name:CENTRAL STATE UNIVERSITY
Entity type:Organization
Organization Name:CENTRAL STATE UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHEWS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-376-6076
Mailing Address - Street 1:P.O. BOX 1004
Mailing Address - Street 2:
Mailing Address - City:WILBERFORCE
Mailing Address - State:OH
Mailing Address - Zip Code:45384
Mailing Address - Country:US
Mailing Address - Phone:937-376-6076
Mailing Address - Fax:937-376-6446
Practice Address - Street 1:1400 BRUSH ROW RD.
Practice Address - Street 2:
Practice Address - City:WILBERFORCE
Practice Address - State:OH
Practice Address - Zip Code:45384
Practice Address - Country:US
Practice Address - Phone:937-376-6076
Practice Address - Fax:937-376-6647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-23
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty