Provider Demographics
NPI:1972627065
Name:GREGORY J. FACEMYER, M.D., LLC
Entity type:Organization
Organization Name:GREGORY J. FACEMYER, M.D., LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:FACEMYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-533-7210
Mailing Address - Street 1:8023 MAPLEVALE DRIVE
Mailing Address - Street 2:
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406
Mailing Address - Country:US
Mailing Address - Phone:330-533-7210
Mailing Address - Fax:
Practice Address - Street 1:5121 MAHONING AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44515-1847
Practice Address - Country:US
Practice Address - Phone:330-799-3223
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35072943F207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2125542Medicaid
OH2125542Medicaid
OH9368441Medicare PIN