1053400507 NPI number — TOWPATH TRAIL FAMILY MEDICINE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053400507 NPI number — TOWPATH TRAIL FAMILY MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TOWPATH TRAIL FAMILY MEDICINE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
TIGERTOWN FAMILY PRACTICE INC.
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053400507
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/17/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 80690
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANTON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44708
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-833-5530
Provider Business Mailing Address Fax Number:
330-833-6085

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1230 MARKET ST NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NAVARRE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44662
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-879-5983
Provider Business Practice Location Address Fax Number:
330-879-9527
Provider Enumeration Date:
10/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
COTIAUX
Authorized Official First Name:
GERTRUDE
Authorized Official Middle Name:
P
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
330-879-5983

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2813754 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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