1093813537 NPI number — HEALTHWORKS MED GROUP OF OHIO CORP., P.A.

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 1093813537 NPI number — HEALTHWORKS MED GROUP OF OHIO CORP., P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEALTHWORKS MED GROUP OF OHIO CORP., P.A.
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:
Provider Other Organization Name Type Code:
6
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:
1093813537
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/29/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16906 COLLECTION CENTER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60693-0169
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-865-9013
Provider Business Mailing Address Fax Number:
217-709-2345

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
311 CALDWELL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHILLICOTHEE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45601-3332
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-773-3374
Provider Business Practice Location Address Fax Number:
740-775-6999
Provider Enumeration Date:
09/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BROOME
Authorized Official First Name:
ROCHELLE
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
615-468-6554

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)





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