1255506713 NPI number — PRIMESOURCE HEALTHCARE OF OHIO, INC.

Table of content: (NPI 1255506713)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255506713 NPI number — PRIMESOURCE HEALTHCARE OF OHIO, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRIMESOURCE HEALTHCARE OF OHIO, 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:
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:
1255506713
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/11/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2100 EAST LAKE COOK ROAD
Provider Second Line Business Mailing Address:
SUITE 1100
Provider Business Mailing Address City Name:
BUFFALO GROVE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60089-1815
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-267-8200
Provider Business Mailing Address Fax Number:
877-821-6402

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4449 EASTON WAY
Provider Second Line Business Practice Location Address:
FLOOR 2
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43219-6093
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-317-0711
Provider Business Practice Location Address Fax Number:
847-267-9440
Provider Enumeration Date:
04/25/2008

Additional Information

Authorized Official

Authorized Official Last Name:
FLEMING
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT & CEO
Authorized Official Telephone Number:
847-267-8200

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2758350 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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