Basic Information
| Provider Information | |||||||||
| NPI: | 1679514749 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUDIMACK | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2774 TIMBER CREEK DR N | ||||||||
| Address2: | |||||||||
| City: | CORTLAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 444101756 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1350 E MARKET ST | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 444836608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308419011 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 35053601S | OH | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0894975 | 05 | OH | MEDICAID | 942460636064 | 01 | OH | CARESOURCE | OTHER |