Basic Information
| Provider Information | |||||||||
| NPI: | 1467636399 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FISHER-TITUS MEDICAL CARE LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 272 BENEDICT AVENUE | ||||||||
| Address2: | |||||||||
| City: | NORWALK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196688101 | ||||||||
| FaxNumber: | 4196602686 | ||||||||
| Practice Location | |||||||||
| Address1: | 272 BENEDICT AVENUE | ||||||||
| Address2: | |||||||||
| City: | NORWALK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196688101 | ||||||||
| FaxNumber: | 4196602686 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2007 | ||||||||
| LastUpdateDate: | 12/05/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DELGADO | ||||||||
| AuthorizedOfficialFirstName: | LAURIE | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT, OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 4196606931 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FISHER-TITUS MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OH | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 36D0946912 | 01 | CLIA | OTHER | 2807109 | 05 | OH | MEDICAID | DG8412 | 01 | OH | MEDICARE RR | OTHER |