Basic Information
| Provider Information | |||||||||
| NPI: | 1447226931 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THORNVILLE FAMILY MEDICAL CENTER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 550 | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 431300550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7406875164 | ||||||||
| FaxNumber: | 7406541417 | ||||||||
| Practice Location | |||||||||
| Address1: | 41 FOSTER DR | ||||||||
| Address2: | |||||||||
| City: | THORNVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7402466361 | ||||||||
| FaxNumber: | 7402464722 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2006 | ||||||||
| LastUpdateDate: | 03/16/2010 | ||||||||
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| AuthorizedOfficialLastName: | COWAN | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
| AuthorizedOfficialMiddleName: | I | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7402466361 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0511413 | 05 | OH | MEDICAID |