Basic Information
| Provider Information | |||||||||
| NPI: | 1497844161 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY MEDICAL CENTER OF ALLIANCE, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 149 E SIMPSON ST | ||||||||
| Address2: | |||||||||
| City: | ALLIANCE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446014219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308233856 | ||||||||
| FaxNumber: | 3308296688 | ||||||||
| Practice Location | |||||||||
| Address1: | 149 E SIMPSON ST | ||||||||
| Address2: | |||||||||
| City: | ALLIANCE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446014219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308233856 | ||||||||
| FaxNumber: | 3308296688 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 06/30/2010 | ||||||||
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| AuthorizedOfficialLastName: | HOOVER | ||||||||
| AuthorizedOfficialFirstName: | MARGI | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3308233856 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 |
ID Information
| ID | Type | State | Issuer | Description | 335551 | 05 | OH | MEDICAID | CB3053 | 01 | OH | MEDICARE RR | OTHER |