Basic Information
| Provider Information | |||||||||
| NPI: | 1104936624 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BES OF OHIO, LLC, DBA MEDGROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 567 | ||||||||
| Address2: | |||||||||
| City: | CHAGRIN FALLS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440220567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2164645160 | ||||||||
| FaxNumber: | 2164645983 | ||||||||
| Practice Location | |||||||||
| Address1: | 3913 DARROW RD | ||||||||
| Address2: | SUITE #100 | ||||||||
| City: | STOW | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442242621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306887900 | ||||||||
| FaxNumber: | 3306881866 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 08/29/2007 | ||||||||
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| AuthorizedOfficialLastName: | ERICKSON | ||||||||
| AuthorizedOfficialFirstName: | DEAN | ||||||||
| AuthorizedOfficialMiddleName: | W. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3308641916 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.