Basic Information
| Provider Information | |||||||||
| NPI: | 1225080591 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUPERIOR MED LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1251 CLARK ST | ||||||||
| Address2: | |||||||||
| City: | CAMBRIDGE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437259612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404390733 | ||||||||
| FaxNumber: | 7404398996 | ||||||||
| Practice Location | |||||||||
| Address1: | 10095 BRICK CHURCH RD | ||||||||
| Address2: | |||||||||
| City: | CAMBRIDGE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437258550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404354022 | ||||||||
| FaxNumber: | 7404354028 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 12/29/2020 | ||||||||
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| AuthorizedOfficialLastName: | JEVAS | ||||||||
| AuthorizedOfficialFirstName: | TOM | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7404352404 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 0915013 | 05 | OH | MEDICAID |