1205019643 NPI number — NORTHEAST FAMILY PRACTICE

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 1205019643 NPI number — NORTHEAST FAMILY PRACTICE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHEAST FAMILY PRACTICE
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:
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:
1205019643
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6200 CLEVELAND AVE
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43231-8608
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
614-898-0150
Provider Business Mailing Address Fax Number:
614-898-0694

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6200 CLEVELAND AVE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43231-8608
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-898-0150
Provider Business Practice Location Address Fax Number:
614-898-0694
Provider Enumeration Date:
12/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BLAKELY
Authorized Official First Name:
KEITH
Authorized Official Middle Name:
ALLEN
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
614-898-0150

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  052152 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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