Basic Information
| Provider Information | |||||||||
| NPI: | 1659475762 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OHIO HILLS HEALTH SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | OHIO HILLS HEALTH CENTER FREEPORT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 101 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BARNESVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437131005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7402396447 | ||||||||
| FaxNumber: | 7406583489 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 WEST MAIN ST | ||||||||
| Address2: | |||||||||
| City: | FREEPORT | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43973 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7406583329 | ||||||||
| FaxNumber: | 7406583489 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2006 | ||||||||
| LastUpdateDate: | 11/03/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRITTON | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7402396447 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OHIO HILLS HEALTH SERVICES | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 0503388 | 05 | OH | MEDICAID | OH3618281 | 01 | OH | MEDICARE FQHC PIN | OTHER |