Basic Information
| Provider Information | |||||||||
| NPI: | 1760461693 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AEBI | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | AEBI | ||||||||
| OtherFirstName: | MARK | ||||||||
| OtherMiddleName: | ELLIS | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1800 GRANVILLE PIKE | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 431301043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7407854678 | ||||||||
| FaxNumber: | 7406871518 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 GRANVILLE PIKE | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 431301043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7407854678 | ||||||||
| FaxNumber: | 7406871518 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2006 | ||||||||
| LastUpdateDate: | 02/22/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35058926 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0773266 | 05 | OH | MEDICAID |