Basic Information
| Provider Information | |||||||||
| NPI: | 1205864337 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OHIO HOSPITAL-BASED PHYSICIAN CORPORATION | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2600 6TH STREET SW | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304529911 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6100 WHIPPLE AVE | ||||||||
| Address2: | |||||||||
| City: | NORTH CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303056999 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 05/23/2022 | ||||||||
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| AuthorizedOfficialLastName: | BESTIC | ||||||||
| AuthorizedOfficialFirstName: | FAITH | ||||||||
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| AuthorizedOfficialTitleorPosition: | PFS ANALYST | ||||||||
| AuthorizedOfficialTelephone: | 3303637462 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 2119513 | 05 | OH | MEDICAID |