Basic Information
| Provider Information | |||||||||
| NPI: | 1578870911 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDICAL HOME PRIMARY CARE CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1821 | ||||||||
| Address2: | |||||||||
| City: | ZANESVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437021821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404553304 | ||||||||
| FaxNumber: | 7404553686 | ||||||||
| Practice Location | |||||||||
| Address1: | 3620 COURT DR | ||||||||
| Address2: | |||||||||
| City: | ZANESVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437016456 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404541248 | ||||||||
| FaxNumber: | 7404548183 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2010 | ||||||||
| LastUpdateDate: | 09/07/2010 | ||||||||
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| AuthorizedOfficialLastName: | CROWDER | ||||||||
| AuthorizedOfficialFirstName: | CHERYL | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7404553304 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35075041D | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2078648 | 05 | OH | MEDICAID |