Basic Information
Provider Information | |||||||||
NPI: | 1689695652 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AULTMAN HEALTH FOUNDATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | AULTMAN HOSPITAL URGENT CARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6100 WHIPPLE AVE NW | ||||||||
Address2: |   | ||||||||
City: | NORTH CANTON | ||||||||
State: | OH | ||||||||
PostalCode: | 447207618 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3303056999 | ||||||||
FaxNumber: | 3303056997 | ||||||||
Practice Location | |||||||||
Address1: | 6100 WHIPPLE AVE NW | ||||||||
Address2: |   | ||||||||
City: | NORTH CANTON | ||||||||
State: | OH | ||||||||
PostalCode: | 447207618 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3303056999 | ||||||||
FaxNumber: | 3303056997 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/22/2006 | ||||||||
LastUpdateDate: | 04/29/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MCDONOUGH | ||||||||
AuthorizedOfficialFirstName: | G SCOTT | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 3308341111 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X |   |   | N |   | Suppliers | Pharmacy |   | 3336C0002X | 021051600 | OH | Y |   | Suppliers | Pharmacy | Clinic Pharmacy |
ID Information
ID | Type | State | Issuer | Description | 2113859 | 05 | OH |   | MEDICAID | 3674428 | 01 |   | NCPDP PROVIDER IDENTIFICATION NUMBER | OTHER |