Provider Demographics
NPI:1194892133
Name:THERESA M.HOM DO LLC
Entity type:Organization
Organization Name:THERESA M.HOM DO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:M
Authorized Official - Last Name:HOM
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:614-840-0380
Mailing Address - Street 1:1000 HIGH ST
Mailing Address - Street 2:SUITE I
Mailing Address - City:WORTHINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43085-4044
Mailing Address - Country:US
Mailing Address - Phone:614-840-0380
Mailing Address - Fax:614-840-0385
Practice Address - Street 1:1000 HIGH ST
Practice Address - Street 2:SUITE I
Practice Address - City:WORTHINGTON
Practice Address - State:OH
Practice Address - Zip Code:43085-4044
Practice Address - Country:US
Practice Address - Phone:614-840-0380
Practice Address - Fax:614-840-0385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-004010207Q00000X, 261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1932123379Other1932123379
OHA16778Medicare UPIN