Provider Demographics
NPI:1487922548
Name:NORTHERN OHIO MEDICAL SPECIALISTS, LLC
Entity type:Organization
Organization Name:NORTHERN OHIO MEDICAL SPECIALISTS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDNTIALING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:WITTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-626-6161
Mailing Address - Street 1:PO BOX 631971
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-1971
Mailing Address - Country:US
Mailing Address - Phone:419-626-6161
Mailing Address - Fax:419-502-3511
Practice Address - Street 1:2800 HAYES AVE # BDLGC130
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870
Practice Address - Country:US
Practice Address - Phone:419-502-5941
Practice Address - Fax:419-502-5942
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHERN OHIO MEDIAL SPECIALISTS,LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-12-05
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH10G07212003261QR0200X
261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2253556Medicaid
OHH240932Medicare PIN