1881706091 NPI number — GRANT/RIVERSIDE MEDICAL CARE FOUNDATION

Table of content: (NPI 1881706091)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881706091 NPI number — GRANT/RIVERSIDE MEDICAL CARE FOUNDATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRANT/RIVERSIDE MEDICAL CARE FOUNDATION
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:
TRICOUNTY FAMILY MEDICINE
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:
1881706091
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5350 FRANTZ RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DUBLIN
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43016-4259
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11925 LITHOPOLIS RD NW
Provider Second Line Business Practice Location Address:
TRICOUNTY FAMILY MEDICINE
Provider Business Practice Location Address City Name:
CANAL WINCHESTER
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43110-9585
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-837-6363
Provider Business Practice Location Address Fax Number:
614-837-0425
Provider Enumeration Date:
09/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HEDGES
Authorized Official First Name:
TRACY
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING SPECIALIST
Authorized Official Telephone Number:
614-544-6356

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

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




Copyright © 2007-2024 www.npivalidator.com