Basic Information
| Provider Information | |||||||||
| NPI: | 1467577502 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DRS. MILBURN - MEDINA, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 409 NORTH COURT ST | ||||||||
| Address2: | |||||||||
| City: | MEDINA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307254680 | ||||||||
| FaxNumber: | 3307252010 | ||||||||
| Practice Location | |||||||||
| Address1: | 409 NORTH COURT ST | ||||||||
| Address2: | |||||||||
| City: | MEDINA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307254680 | ||||||||
| FaxNumber: | 3307252010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2007 | ||||||||
| LastUpdateDate: | 11/16/2016 | ||||||||
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| AuthorizedOfficialLastName: | MILBURN | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | MICHAEL | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3307254680 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | O.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 5133 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 2980449 | 05 | OH | MEDICAID |