Basic Information
| Provider Information | |||||||||
| NPI: | 1801826607 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FIRST CAPITAL INTERNAL MEDICINE, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4437 ST. RT. 159 | ||||||||
| Address2: | SUITE 115 | ||||||||
| City: | CHILLICOTHE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7407752652 | ||||||||
| FaxNumber: | 7407752699 | ||||||||
| Practice Location | |||||||||
| Address1: | 4437 ST. RT. 159 | ||||||||
| Address2: | SUITE 115 | ||||||||
| City: | CHILLICOTHE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7407752652 | ||||||||
| FaxNumber: | 7407752699 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 04/04/2008 | ||||||||
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| AuthorizedOfficialLastName: | BERNO | ||||||||
| AuthorizedOfficialFirstName: | JACK | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CHAIRMAN | ||||||||
| AuthorizedOfficialTelephone: | 7407752652 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35047244B | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2199973 | 05 | OH | MEDICAID |