Provider Demographics
NPI:1871548164
Name:SYCAMORE PRIMARY CARE GROUP
Entity type:Organization
Organization Name:SYCAMORE PRIMARY CARE GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:Y
Authorized Official - Last Name:KO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-558-3208
Mailing Address - Street 1:10050 INNOVATION DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-4931
Mailing Address - Country:US
Mailing Address - Phone:937-558-3208
Mailing Address - Fax:937-558-3247
Practice Address - Street 1:2115 LEITER RD
Practice Address - Street 2:
Practice Address - City:MIAMISBURG
Practice Address - State:OH
Practice Address - Zip Code:45342-3659
Practice Address - Country:US
Practice Address - Phone:937-384-6842
Practice Address - Fax:937-384-6939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0227829Medicaid
OHSY9283031OtherMEDICARE
OH0227829Medicaid
OHSY9283031OtherMEDICARE