Provider Demographics
NPI:1083892525
Name:STARK COUNTY INTERNAL MEDICINE INC
Entity type:Organization
Organization Name:STARK COUNTY INTERNAL MEDICINE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:OBERLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-497-8636
Mailing Address - Street 1:1401 S MAIN ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-4289
Mailing Address - Country:US
Mailing Address - Phone:330-497-8636
Mailing Address - Fax:330-497-8634
Practice Address - Street 1:1401 S MAIN ST
Practice Address - Street 2:SUITE 101
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-4289
Practice Address - Country:US
Practice Address - Phone:330-497-8636
Practice Address - Fax:330-497-8634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-06
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35076929-O207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2243594Medicaid
SP00931OtherMEDICARE GROUP NUMBER
OH2243594Medicaid