Basic Information
| Provider Information | |||||||||
| NPI: | 1306836002 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MEYER | ||||||||
| FirstName: | MARK | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3515 MASSILLON RD | ||||||||
| Address2: | STE 300 | ||||||||
| City: | UNIONTOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446857854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308999350 | ||||||||
| FaxNumber: | 3306341329 | ||||||||
| Practice Location | |||||||||
| Address1: | 65 COMMUNITY RD | ||||||||
| Address2: | SUITE C | ||||||||
| City: | TALLMADGE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442782357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306336601 | ||||||||
| FaxNumber: | 3306302941 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2005 | ||||||||
| LastUpdateDate: | 09/12/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35050600M | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0567499 | 05 | OH | MEDICAID |