Basic Information
| Provider Information | |||||||||
| NPI: | 1609123728 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OHIOGUIDESTONE | ||||||||
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| OtherOrganizationName: | GUIDESTONE | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 434 EASTLAND ROAD | ||||||||
| Address2: | |||||||||
| City: | BEREA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440172058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402608327 | ||||||||
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| Practice Location | |||||||||
| Address1: | 202 E BAGLEY RD | ||||||||
| Address2: | |||||||||
| City: | BEREA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440172058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402608379 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2012 | ||||||||
| LastUpdateDate: | 11/20/2017 | ||||||||
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| AuthorizedOfficialLastName: | JACKSON | ||||||||
| AuthorizedOfficialFirstName: | MANDY | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 4402608328 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0006X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Developmental – Behavioral Pediatrics |
No ID Information.