Provider Demographics
NPI:1528053352
Name:MOUNT VERNON FAMILY PRACTICE INC
Entity type:Organization
Organization Name:MOUNT VERNON FAMILY PRACTICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AMY
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:MURNEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:740-397-2244
Mailing Address - Street 1:10 WOODLAKE TRL
Mailing Address - Street 2:SUITE B
Mailing Address - City:MOUNT VERNON
Mailing Address - State:OH
Mailing Address - Zip Code:43050-9573
Mailing Address - Country:US
Mailing Address - Phone:740-397-2244
Mailing Address - Fax:740-397-2993
Practice Address - Street 1:10 WOODLAKE TRL
Practice Address - Street 2:SUITE B
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-9573
Practice Address - Country:US
Practice Address - Phone:740-397-2244
Practice Address - Fax:740-397-2993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-19
Last Update Date:2008-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35069571207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH35069571OtherSTATE MEDICAL LICENSE
OH2499970Medicaid
OHG55230Medicare UPIN
OHMO9342191Medicare ID - Type UnspecifiedMEDICARE GROUP #