Provider Demographics
NPI:1053657098
Name:MY PRACTITONER FAMILY PRACTICE
Entity Type:Organization
Organization Name:MY PRACTITONER FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:BROCK
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:513-748-0874
Mailing Address - Street 1:2996 STATE ROUTE 132
Mailing Address - Street 2:
Mailing Address - City:AMELIA
Mailing Address - State:OH
Mailing Address - Zip Code:45102-2404
Mailing Address - Country:US
Mailing Address - Phone:513-748-0874
Mailing Address - Fax:513-322-7989
Practice Address - Street 1:2996 STATE ROUTE 132
Practice Address - Street 2:
Practice Address - City:AMELIA
Practice Address - State:OH
Practice Address - Zip Code:45102-2404
Practice Address - Country:US
Practice Address - Phone:513-748-0874
Practice Address - Fax:513-322-7989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-19
Last Update Date:2013-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.13223-NP364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH080402Medicare PIN