Basic Information
| Provider Information | |||||||||
| NPI: | 1053400507 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TOWPATH TRAIL FAMILY MEDICINE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TIGERTOWN FAMILY PRACTICE INC. | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 80690 | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308335530 | ||||||||
| FaxNumber: | 3308336085 | ||||||||
| Practice Location | |||||||||
| Address1: | 1230 MARKET ST NE | ||||||||
| Address2: | |||||||||
| City: | NAVARRE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308795983 | ||||||||
| FaxNumber: | 3308799527 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 06/17/2008 | ||||||||
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| AuthorizedOfficialLastName: | COTIAUX | ||||||||
| AuthorizedOfficialFirstName: | GERTRUDE | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3308795983 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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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 | 2813754 | 05 | OH | MEDICAID |