Basic Information
| Provider Information | |||||||||
| NPI: | 1801847264 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FINEFROCK | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 PROSPECT AVE | ||||||||
| Address2: | |||||||||
| City: | HACKENSACK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076011915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5519963547 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3000 MACK RD | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450145335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138707001 | ||||||||
| FaxNumber: | 5136038174 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 01/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 25MB09066300 | NJ | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 34008054 | OH | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000316069 | 01 | OH | BCBS FAIRFIELD | OTHER | P00083370 | 01 | RR MEDICARE FAIRFIELD | OTHER | 2424746 | 05 | OH | MEDICAID |