Provider Demographics
NPI:1437436193
Name:NORTHERN OHIO MEDICAL SPECIALISTS,LLC
Entity type:Organization
Organization Name:NORTHERN OHIO MEDICAL SPECIALISTS,LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:
Authorized Official - Last Name:FREDERICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-626-6161
Mailing Address - Street 1:PO BOX 378
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44871-0378
Mailing Address - Country:US
Mailing Address - Phone:419-609-1112
Mailing Address - Fax:419-609-1123
Practice Address - Street 1:25761 LORAIN RD
Practice Address - Street 2:FLOOR 2
Practice Address - City:NORTH OLMSTED
Practice Address - State:OH
Practice Address - Zip Code:44070-3368
Practice Address - Country:US
Practice Address - Phone:440-779-9633
Practice Address - Fax:440-779-9636
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHERN OHIO MEDICAL SPECIALSIST,LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-11-09
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH10C07212002261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2154350Medicaid
OH2154350Medicaid