Basic Information
| Provider Information | |||||||||
| NPI: | 1265700520 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PARTNERS PHYSICIAN GROUP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CARDIAC, THORACIC & VASCULAR SPECIALISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1761 BEALL AVE | ||||||||
| Address2: | |||||||||
| City: | WOOSTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446912342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303441400 | ||||||||
| FaxNumber: | 3303440112 | ||||||||
| Practice Location | |||||||||
| Address1: | 1761 BEALL AVE | ||||||||
| Address2: | |||||||||
| City: | WOOSTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446912342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303441400 | ||||||||
| FaxNumber: | 3303440112 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2011 | ||||||||
| LastUpdateDate: | 06/22/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRAMAN | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF MEDICAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3306658302 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | OH | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 2086S0129X | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 9338635 | 01 | OH | PARTNERS PHYSICIAN GROUP MEDICARE GROUP # | OTHER | 2551671 | 01 | OH | PARTNERS PHYSICIAN GROUP MEDICAID GROUP # | OTHER | 1841239274 | 01 | OH | PARTNERS PHYSICIAN GROUP TYPE 2 NPI # | OTHER |