Provider Demographics
NPI:1003076431
Name:OCCMED SOURCE, LLC
Entity Type:Organization
Organization Name:OCCMED SOURCE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MOTEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:330-548-0086
Mailing Address - Street 1:174 CURRIE HALL PKWY
Mailing Address - Street 2:SUITE D
Mailing Address - City:KENT
Mailing Address - State:OH
Mailing Address - Zip Code:44240-4387
Mailing Address - Country:US
Mailing Address - Phone:330-548-0086
Mailing Address - Fax:330-548-0085
Practice Address - Street 1:174 CURRIE HALL PKWY
Practice Address - Street 2:SUITE D
Practice Address - City:KENT
Practice Address - State:OH
Practice Address - Zip Code:44240-4387
Practice Address - Country:US
Practice Address - Phone:330-548-0086
Practice Address - Fax:330-548-0085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-10
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty