Provider Demographics
NPI:1124067160
Name:PARTNERS PHYSICIAN GROUP
Entity type:Organization
Organization Name:PARTNERS PHYSICIAN GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER, PPG
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-665-8302
Mailing Address - Street 1:225 ELYRIA ST
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:OH
Mailing Address - Zip Code:44254-1031
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:225 ELYRIA ST
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:OH
Practice Address - Zip Code:44254-1031
Practice Address - Country:US
Practice Address - Phone:330-344-3583
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-05
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH207RC0000X, 207V00000X, 207RC0001X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac ElectrophysiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9338635OtherPARTNERS PHYSICIAN GROUP MEDICARE GROUP #
OH1841239274OtherPARTNERS PHYSICIAN GROUP TYPE 2 NPI #
OH2551671OtherPARTNERS PHYSICIAN GROUP MEDICAID GROUP #