Basic Information
Provider Information
NPI: 1003806209
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: ANTHONY
FirstName: JAMES
MiddleName: M
NamePrefix:  
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1800 LIVINGSTON AVE
Address2: SUITE 200
City: LORAIN
State: OH
PostalCode: 440523781
CountryCode: US
TelephoneNumber: 4402331068
FaxNumber: 4402331028
Practice Location
Address1: 1800 LIVINGSTON AVE
Address2: SUITE 200
City: LORAIN
State: OH
PostalCode: 440523781
CountryCode: US
TelephoneNumber: 4402331068
FaxNumber: 4402331028
Other Information
ProviderEnumerationDate: 10/27/2005
LastUpdateDate: 01/23/2012
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207QS0010X35045275OHN Allopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
2083X0100X35045275OHY Allopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine

ID Information
IDTypeStateIssuerDescription
048764705OH MEDICAID


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