Basic Information
| Provider Information | |||||||||
| NPI: | 1962501056 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SYCAMORE MEDICAL ASSOCIATES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 103 N PENNINGTON ST | ||||||||
| Address2: | |||||||||
| City: | SYCAMORE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448829408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199276552 | ||||||||
| FaxNumber: | 4199276500 | ||||||||
| Practice Location | |||||||||
| Address1: | 103 N PENNINGTON ST | ||||||||
| Address2: | |||||||||
| City: | SYCAMORE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448829408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199276552 | ||||||||
| FaxNumber: | 4199276500 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 10/13/2009 | ||||||||
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| AuthorizedOfficialLastName: | CISAR | ||||||||
| AuthorizedOfficialFirstName: | N | ||||||||
| AuthorizedOfficialMiddleName: | SCOTT | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4199276552 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0228060 | 05 | OH | MEDICAID |