Provider Demographics
NPI:1902595754
Name:OHP IA NETWORK, LLC
Entity type:Organization
Organization Name:OHP IA NETWORK, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-908-4858
Mailing Address - Street 1:4632 RESERVOIR RD NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20007-1917
Mailing Address - Country:US
Mailing Address - Phone:301-908-4858
Mailing Address - Fax:
Practice Address - Street 1:4632 RESERVOIR RD NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20007-1917
Practice Address - Country:US
Practice Address - Phone:301-908-4858
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-05
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty