Provider Demographics
NPI:1093183204
Name:SHADYSIDE CLINIC, LLC
Entity Type:Organization
Organization Name:SHADYSIDE CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER AND OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LINDSAY
Authorized Official - Middle Name:
Authorized Official - Last Name:TWAROG
Authorized Official - Suffix:
Authorized Official - Credentials:CFNP
Authorized Official - Phone:740-298-2475
Mailing Address - Street 1:65855 STONE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:OH
Mailing Address - Zip Code:43718-9425
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3948 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:SHADYSIDE
Practice Address - State:OH
Practice Address - Zip Code:43947-1310
Practice Address - Country:US
Practice Address - Phone:740-298-2475
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-03
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH16718NP261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care