1104936624 NPI number — BES OF OHIO, LLC, DBA MEDGROUP

Table of content: (NPI 1104936624)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104936624 NPI number — BES OF OHIO, LLC, DBA MEDGROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BES OF OHIO, LLC, DBA MEDGROUP
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:
1104936624
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/29/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 567
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHAGRIN FALLS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44022-0567
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-464-5160
Provider Business Mailing Address Fax Number:
216-464-5983

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3913 DARROW RD
Provider Second Line Business Practice Location Address:
SUITE #100
Provider Business Practice Location Address City Name:
STOW
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44224-2621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-688-7900
Provider Business Practice Location Address Fax Number:
330-688-1866
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ERICKSON
Authorized Official First Name:
DEAN
Authorized Official Middle Name:
W.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
330-864-1916

Provider Taxonomy Codes

  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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