Basic Information
Provider Information | |||||||||
NPI: | 1053400507 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TOWPATH TRAIL FAMILY MEDICINE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | TIGERTOWN FAMILY PRACTICE INC. | ||||||||
OtherOrganizationType: | 4 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | COTIAUX | ||||||||
AuthorizedOfficialFirstName: | GERTRUDE | ||||||||
AuthorizedOfficialMiddleName: | P | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 3308795983 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
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 |