Basic Information
Provider Information | |||||||||
NPI: | 1851591887 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DERMATOLOGY ALLERGY GENERAL PHYSICIANS OF OHIO INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5212 BRANDT PIKE | ||||||||
Address2: | SUITE A | ||||||||
City: | HUBER HEIGHTS | ||||||||
State: | OH | ||||||||
PostalCode: | 454246138 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9372330748 | ||||||||
FaxNumber: | 9372336086 | ||||||||
Practice Location | |||||||||
Address1: | 300 PATRICK AVENUE | ||||||||
Address2: |   | ||||||||
City: | URBANA | ||||||||
State: | OH | ||||||||
PostalCode: | 430782339 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9376521257 | ||||||||
FaxNumber: | 9374847913 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/18/2007 | ||||||||
LastUpdateDate: | 09/24/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MCFARLAND | ||||||||
AuthorizedOfficialFirstName: | THERESA | ||||||||
AuthorizedOfficialMiddleName: | LYNN | ||||||||
AuthorizedOfficialTitleorPosition: | CORPORATION SECRETARY | ||||||||
AuthorizedOfficialTelephone: | 9372330748 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35058434M | OH | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207ZP0105X | 34003765M | OH | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine | 207N00000X | 35043565M | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |   |
ID Information
ID | Type | State | Issuer | Description | 000000011382 | 01 | OH | ANTHEM PIN-N | OTHER | 368588672030 | 01 | OH | MMO PIN-N | OTHER | 36D0350348 | 01 | OH | CLIA | OTHER | 9190169 | 01 | OH | PTAN | OTHER | 485805933016 | 01 | OH | MMO PIN-P | OTHER | 000000011389 | 01 | OH | ANTHEM PIN | OTHER | 394601220026 | 01 | OH | MMO PIN | OTHER | 000000011437 | 01 | OH | ANTHEM PIN-F | OTHER | 485805933033 | 01 | OH | MMO PIN-F | OTHER |