Basic Information
| Provider Information | |||||||||
| NPI: | 1275793028 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BUCKEYE BEHAVIORAL HEALTH LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2779 | ||||||||
| Address2: | |||||||||
| City: | ALLIANCE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446010779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308299389 | ||||||||
| FaxNumber: | 3308299372 | ||||||||
| Practice Location | |||||||||
| Address1: | 4888 ARMANDALE AVE NW | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447182284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308299389 | ||||||||
| FaxNumber: | 3308299372 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2008 | ||||||||
| LastUpdateDate: | 12/09/2010 | ||||||||
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| AuthorizedOfficialLastName: | THALLURI | ||||||||
| AuthorizedOfficialFirstName: | RANGA | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PSYCHIATRY | ||||||||
| AuthorizedOfficialTelephone: | 3308299389 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 35062816 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 0987106 | 05 | OH | MEDICAID |