Provider Demographics
NPI:1992059380
Name:NORTHCOAST MEDICAL GROUP LLC
Entity type:Organization
Organization Name:NORTHCOAST MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:440-785-5278
Mailing Address - Street 1:5325 SOM CENTER RD
Mailing Address - Street 2:
Mailing Address - City:SOLON
Mailing Address - State:OH
Mailing Address - Zip Code:44139-1459
Mailing Address - Country:US
Mailing Address - Phone:440-785-5278
Mailing Address - Fax:
Practice Address - Street 1:5325 SOM CENTER RD
Practice Address - Street 2:
Practice Address - City:SOLON
Practice Address - State:OH
Practice Address - Zip Code:44139-1459
Practice Address - Country:US
Practice Address - Phone:440-785-5278
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-06
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-007383208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty