Basic Information
| Provider Information | |||||||||
| NPI: | 1962513747 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIAMOND FAMILY PRACTICE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 87 CONSERVATORY DR | ||||||||
| Address2: | SUITE B | ||||||||
| City: | BARBERTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442034291 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307532400 | ||||||||
| FaxNumber: | 3307533878 | ||||||||
| Practice Location | |||||||||
| Address1: | 87 CONSERVATORY DR | ||||||||
| Address2: | SUITE B | ||||||||
| City: | BARBERTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442034291 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307532400 | ||||||||
| FaxNumber: | 3307533878 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SOBOLEWSKI | ||||||||
| AuthorizedOfficialFirstName: | ERIKA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 3307532400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2267989 | 05 | OH | MEDICAID |