Basic Information
Provider Information | |||||||||
NPI: | 1619004470 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | UNIVERSITY PRIMARY CARE PRACTICES INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | UH QCARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 8792 | ||||||||
Address2: |   | ||||||||
City: | BELFAST | ||||||||
State: | ME | ||||||||
PostalCode: | 049158792 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2163836776 | ||||||||
FaxNumber: | 2163836745 | ||||||||
Practice Location | |||||||||
Address1: | 350 HILLCREST DR | ||||||||
Address2: | STE 3 | ||||||||
City: | ASHLAND | ||||||||
State: | OH | ||||||||
PostalCode: | 448054052 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4192072502 | ||||||||
FaxNumber: | 4192072394 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/28/2007 | ||||||||
LastUpdateDate: | 01/30/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LADER | ||||||||
AuthorizedOfficialFirstName: | GABRIEL | ||||||||
AuthorizedOfficialMiddleName: | E | ||||||||
AuthorizedOfficialTitleorPosition: | SR BUSINESS OPERATIONS ANALYST | ||||||||
AuthorizedOfficialTelephone: | 2163582348 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X |   | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
No ID Information.