Basic Information
| Provider Information | |||||||||
| NPI: | 1891960720 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDCOSMETIX, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 241 EXECUTIVE DR | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433026307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403873256 | ||||||||
| FaxNumber: | 7403834906 | ||||||||
| Practice Location | |||||||||
| Address1: | 241 EXECUTIVE DR | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433026307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403873256 | ||||||||
| FaxNumber: | 7403834906 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2008 | ||||||||
| LastUpdateDate: | 04/22/2008 | ||||||||
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| AuthorizedOfficialLastName: | GARNER | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | FRANCIS | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7403873256 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35051305G | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0695805 | 05 | OH | MEDICAID |