Basic Information
| Provider Information | |||||||||
| NPI: | 1023007655 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHYSICIANS IN FAMILY PRACTICE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 319 W LORAIN ST | ||||||||
| Address2: | |||||||||
| City: | OBERLIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4407751881 | ||||||||
| FaxNumber: | 4407745707 | ||||||||
| Practice Location | |||||||||
| Address1: | 319 W LORAIN ST | ||||||||
| Address2: | |||||||||
| City: | OBERLIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4407751881 | ||||||||
| FaxNumber: | 4407745707 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2005 | ||||||||
| LastUpdateDate: | 04/01/2009 | ||||||||
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| AuthorizedOfficialLastName: | JONESCO | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4407751881 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0440384 | 05 | OH | MEDICAID |