1639332240 NPI number — TRUMBULL MAHONING MEDICAL GROUP INC

Table of content: (NPI 1639332240)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639332240 NPI number — TRUMBULL MAHONING MEDICAL GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRUMBULL MAHONING MEDICAL GROUP INC
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:
TMMG URGENT CARE
Provider Other Organization Name Type Code:
3
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:
1639332240
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/17/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2600 ELM ROAD NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORTLAND
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44410
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-372-8895
Provider Business Mailing Address Fax Number:
330-372-8999

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2600 ELM RD NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORTLAND
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44410-9393
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-372-8820
Provider Business Practice Location Address Fax Number:
330-372-8999
Provider Enumeration Date:
07/03/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ROSTOM
Authorized Official First Name:
MOURAD
Authorized Official Middle Name:
Authorized Official Title or Position:
PARTNER/EXECUTIVE
Authorized Official Telephone Number:
330-372-8820

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: 0468677 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1426141 . This is a "HIGHMARK OF PA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 000000243183 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".