Provider Demographics
NPI:1992702963
Name:BREWSERS ATHLETIC CLUB INC
Entity type:Organization
Organization Name:BREWSERS ATHLETIC CLUB INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:F
Authorized Official - Last Name:ALTIERI
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:614-291-1677
Mailing Address - Street 1:849 HARMON AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43223-2411
Mailing Address - Country:US
Mailing Address - Phone:614-291-1677
Mailing Address - Fax:
Practice Address - Street 1:849 HARMON AVE
Practice Address - Street 2:SUITE B
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43223-2411
Practice Address - Country:US
Practice Address - Phone:614-291-1677
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH332B00000X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2133079Medicaid
OH1285180001Medicare ID - Type Unspecified