Basic Information
Provider Information | |||||||||
NPI: | 1689653123 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HA | ||||||||
FirstName: | LINDA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 55 ARCH ST STE 1B | ||||||||
Address2: |   | ||||||||
City: | AKRON | ||||||||
State: | OH | ||||||||
PostalCode: | 443041436 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3303753315 | ||||||||
FaxNumber: | 3303753760 | ||||||||
Practice Location | |||||||||
Address1: | 55 ARCH ST STE 1B | ||||||||
Address2: |   | ||||||||
City: | AKRON | ||||||||
State: | OH | ||||||||
PostalCode: | 443041436 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3303753315 | ||||||||
FaxNumber: | 3303753760 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/12/2006 | ||||||||
LastUpdateDate: | 01/13/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 34-00-6352-H | OH | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 2069078 | 05 | OH |   | MEDICAID | HA0854172 | 01 | OH | MEDICARE ID | OTHER | 0854173 | 01 | OH | MEDICARE ID | OTHER | 110240822 | 01 | OH | RAILROAD MEDICARE | OTHER | 729115 | 01 | OH | BUCKEYE COMMUNITY HEALTH | OTHER | 580 | 01 | OH | SUMMACARE | OTHER | 000000256313 | 01 | OH | ANTHEM | OTHER |