Provider Demographics
NPI:1386726214
Name:SUTTON INTERNAL AND PHYSICAL MEDICINE CLINIC, INC
Entity type:Organization
Organization Name:SUTTON INTERNAL AND PHYSICAL MEDICINE CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:BLAINE
Authorized Official - Last Name:SUTTON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:330-544-1500
Mailing Address - Street 1:1250 YOUNGSTOWN WARREN RD
Mailing Address - Street 2:SUTIE 1A
Mailing Address - City:NILES
Mailing Address - State:OH
Mailing Address - Zip Code:44446-4649
Mailing Address - Country:US
Mailing Address - Phone:330-544-1500
Mailing Address - Fax:330-544-7988
Practice Address - Street 1:1250 YOUNGSTOWN WARREN RD
Practice Address - Street 2:SUTIE 1A
Practice Address - City:NILES
Practice Address - State:OH
Practice Address - Zip Code:44446-4649
Practice Address - Country:US
Practice Address - Phone:330-544-1500
Practice Address - Fax:330-544-7988
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-00-7547-S204D00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2378323Medicaid
OH2378323Medicaid
OHH76235Medicare UPIN