Basic Information
| Provider Information | |||||||||
| NPI: | 1164518825 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AKRON INFECTIOUS DISEASE, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 75 ARCH ST | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443041429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303753894 | ||||||||
| FaxNumber: | 3303756680 | ||||||||
| Practice Location | |||||||||
| Address1: | 75 ARCH ST | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443041429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303753894 | ||||||||
| FaxNumber: | 3303756680 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BONILLA | ||||||||
| AuthorizedOfficialFirstName: | HECTOR | ||||||||
| AuthorizedOfficialMiddleName: | F. | ||||||||
| AuthorizedOfficialTitleorPosition: | MD | ||||||||
| AuthorizedOfficialTelephone: | 3303753894 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 35-08-0197B | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 2278833 | 05 | OH | MEDICAID |