Provider Demographics
NPI:1104904663
Name:INTERDISCIPLINARY MEDICAL MGT
Entity type:Organization
Organization Name:INTERDISCIPLINARY MEDICAL MGT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:A
Authorized Official - Last Name:STYCHNO
Authorized Official - Suffix:
Authorized Official - Credentials:OWNER
Authorized Official - Phone:330-544-3737
Mailing Address - Street 1:2103 NILES CORTLAND RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44484
Mailing Address - Country:US
Mailing Address - Phone:330-544-3737
Mailing Address - Fax:330-544-3904
Practice Address - Street 1:2103 NILES CORTLAND RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484
Practice Address - Country:US
Practice Address - Phone:330-544-3737
Practice Address - Fax:330-544-3904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6881225100000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2365202Medicaid
OHWE4095613Medicare ID - Type Unspecified
OH2365202Medicaid