1902892888 NPI number — BACK ISSUES PC INC

Table of content: (NPI 1902892888)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902892888 NPI number — BACK ISSUES PC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BACK ISSUES PC 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:
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:
1902892888
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
378 S MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PATASKALA
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43062-8392
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
740-964-2081
Provider Business Mailing Address Fax Number:
614-656-4027

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
378 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PATASKALA
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43062-8392
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-964-2081
Provider Business Practice Location Address Fax Number:
614-656-4027
Provider Enumeration Date:
09/26/2005

Additional Information

Authorized Official

Authorized Official Last Name:
KORN
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
ADAM
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
740-964-2081

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2406597 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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