Provider Demographics
NPI:1013008192
Name:MATERNOHIO CLINICAL ASSOCIATES INC
Entity Type:Organization
Organization Name:MATERNOHIO CLINICAL ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:YERINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-641-4024
Mailing Address - Street 1:1700 LAKE SHORE DR STE 350
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43204-4895
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1700 LAKE SHORE DR STE 350
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43204-4895
Practice Address - Country:US
Practice Address - Phone:614-641-4023
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35083946174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHDE1422OtherMEDICARE RAILROAD GROUP NUMBER
OH2586296Medicaid
OH2586296Medicaid