Basic Information
| Provider Information | |||||||||
| NPI: | 1336425669 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JUMP START PRIMARY CARE AND SPORTS MEDICINE, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HERITAGE PRIMARY CARE AND SPORTS MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1069 KLOTZ RD STE A | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 434024820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197280110 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1069 KLOTZ RD STE A | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 434024820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197280110 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2011 | ||||||||
| LastUpdateDate: | 01/12/2012 | ||||||||
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| AuthorizedOfficialLastName: | NOFTZ | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4192023279 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | II | ||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.