Basic Information
| Provider Information | |||||||||
| NPI: | 1629436431 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AMERICAN FAMILY CARE OHIO, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AMERICAN FAMILY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3700 CAHABA BEACH RD | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352425225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2054212098 | ||||||||
| FaxNumber: | 2054212109 | ||||||||
| Practice Location | |||||||||
| Address1: | 3802 PAXTON AVE | ||||||||
| Address2: | STE. 1 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452092399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135599700 | ||||||||
| FaxNumber: | 5135590900 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2016 | ||||||||
| LastUpdateDate: | 02/08/2016 | ||||||||
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| AuthorizedOfficialLastName: | JOHANSEN | ||||||||
| AuthorizedOfficialFirstName: | RANDY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2054038902 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AMERICAN FAMILY CARE, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.