Basic Information
| Provider Information | |||||||||
| NPI: | 1902009327 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DERMATOLOGY ALLERGY GENERAL PHYSICIANS OF OHIO INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5212 BRANDT PIKE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | HUBER HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454246138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372330748 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1820 C STREET | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458041832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192224559 | ||||||||
| FaxNumber: | 4192224589 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2007 | ||||||||
| LastUpdateDate: | 10/05/2009 | ||||||||
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| AuthorizedOfficialLastName: | MCFARLAND | ||||||||
| AuthorizedOfficialFirstName: | THERESA | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | CORPORATION SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 9372330748 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35 05 8434M | OH | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207ZP0105X | 34003765F | OH | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine | 207N00000X | 35 04 3565M | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 485805933022 | 01 | OH | MMO PIN | OTHER | 394601220019 | 01 | OH | MMO PIN | OTHER | 000000011383 | 01 | OH | ANTHEM PIN | OTHER | 000000066851 | 01 | OH | ANTHEM PIN | OTHER | 485805933016 | 01 | OH | MMO PIN | OTHER | 9190167 | 01 | OH | PTAN | OTHER | 000000011437 | 01 | OH | ANTHEM PIN | OTHER | 368588672019 | 01 | OH | MMO PIN | OTHER |