Basic Information
| Provider Information | |||||||||
| NPI: | 1578578233 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ONTARIO MEDICAL ASSOCIATES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2007 W 4TH ST | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449061787 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195296195 | ||||||||
| FaxNumber: | 4195299187 | ||||||||
| Practice Location | |||||||||
| Address1: | 2007 W 4TH ST | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449061787 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195296195 | ||||||||
| FaxNumber: | 4195299187 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2006 | ||||||||
| LastUpdateDate: | 09/20/2007 | ||||||||
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| AuthorizedOfficialLastName: | CARROLL | ||||||||
| AuthorizedOfficialFirstName: | TRICIA | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4195296195 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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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.