Provider Demographics
NPI:1417548256
Name:NIESE FAMILY MEDICINE LLC
Entity type:Organization
Organization Name:NIESE FAMILY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ZACHARY
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:NIESE
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, APRN, FNP-C
Authorized Official - Phone:419-615-2983
Mailing Address - Street 1:2040 ROAD P
Mailing Address - Street 2:
Mailing Address - City:PANDORA
Mailing Address - State:OH
Mailing Address - Zip Code:45877-9733
Mailing Address - Country:US
Mailing Address - Phone:419-615-2983
Mailing Address - Fax:
Practice Address - Street 1:3387 ROAD K3
Practice Address - Street 2:
Practice Address - City:OTTAWA
Practice Address - State:OH
Practice Address - Zip Code:45875-8741
Practice Address - Country:US
Practice Address - Phone:419-615-2983
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-02
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2497822501Medicaid