Basic Information
| Provider Information | |||||||||
| NPI: | 1184652539 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JTDM FAMILY PRACTICE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 SAINT CLAIR AVE | ||||||||
| Address2: | |||||||||
| City: | ST MARYS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458852400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193943335 | ||||||||
| FaxNumber: | 4193948485 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 SAINT CLAIR AVE | ||||||||
| Address2: | |||||||||
| City: | ST MARYS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458852400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193943335 | ||||||||
| FaxNumber: | 4193948485 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 03/23/2022 | ||||||||
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| AuthorizedOfficialLastName: | POHL | ||||||||
| AuthorizedOfficialFirstName: | TRICIA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 4193943335 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207Y00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 2084N0400X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 208800000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | 213E00000X | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213ES0103X | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 367A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.