Basic Information
| Provider Information | |||||||||
| NPI: | 1306803440 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HIGHLAND DISTRICT HOSPITAL PROFESSIONAL SERVICES CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HIGHLAND FAMILY HEALTHCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 70 | ||||||||
| Address2: | 1404 NORTH HIGH STREET | ||||||||
| City: | HILLSBORO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373931129 | ||||||||
| FaxNumber: | 9373931658 | ||||||||
| Practice Location | |||||||||
| Address1: | 1402 N HIGH ST | ||||||||
| Address2: | |||||||||
| City: | HILLSBORO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 451338514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373934899 | ||||||||
| FaxNumber: | 9373934996 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2006 | ||||||||
| LastUpdateDate: | 08/15/2011 | ||||||||
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| AuthorizedOfficialLastName: | COOMER | ||||||||
| AuthorizedOfficialFirstName: | TRACY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP OF PROFESSIONAL SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 9373936100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 2355062 | 05 | OH | MEDICAID |