Basic Information
| Provider Information | |||||||||
| NPI: | 1053431130 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WHOLE FAMILY MEDICAL CARE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7550 LUCERNE DR | ||||||||
| Address2: | SUITE 405 | ||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441306588 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888768833 | ||||||||
| FaxNumber: | 4402343313 | ||||||||
| Practice Location | |||||||||
| Address1: | 28442 E RIVER RD | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | PERRYSBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435512858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198723250 | ||||||||
| FaxNumber: | 4198723258 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2007 | ||||||||
| LastUpdateDate: | 07/29/2015 | ||||||||
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| AuthorizedOfficialLastName: | HOST | ||||||||
| AuthorizedOfficialFirstName: | ELEANOR | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4198723250 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 35065656 | OH | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 0198067 | 05 | OH | MEDICAID |