Basic Information
| Provider Information | |||||||||
| NPI: | 1023060951 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BARBERTON HEALTH SYSTEM LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | BARBERTON CITIZENS HOSPITAL SNF | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 714139 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432714139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307451611 | ||||||||
| FaxNumber: | 3308487820 | ||||||||
| Practice Location | |||||||||
| Address1: | 155 5TH ST NE | ||||||||
| Address2: | |||||||||
| City: | BARBERTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442033332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307451611 | ||||||||
| FaxNumber: | 3308487820 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 11/01/2007 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOLTSFORD | ||||||||
| AuthorizedOfficialFirstName: | LAURIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, BUSINESS OFFICE SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 6154657466 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BARBERTON HEALTH SYSTEM LLC | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 3418 | OH | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0351444 | 05 | OH | MEDICAID |