Basic Information
| Provider Information | |||||||||
| NPI: | 1194058446 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PIONEER PHYSICIANS NETWORK, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SOUTH MAIN STREET MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4880 S MAIN ST | ||||||||
| Address2: | STE 4 | ||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443194474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3309232700 | ||||||||
| FaxNumber: | 3306341329 | ||||||||
| Practice Location | |||||||||
| Address1: | 1640 CORPORATE WOODS CIR | ||||||||
| Address2: | |||||||||
| City: | UNIONTOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446857819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308999350 | ||||||||
| FaxNumber: | 3308999395 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2009 | ||||||||
| LastUpdateDate: | 08/14/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KOSTELNICK | ||||||||
| AuthorizedOfficialFirstName: | KATHLEEN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3308999350 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PIONEER PHYSICIANS NETWORK, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CMM | ||||||||
| NPICertificationDate: | 08/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.