Provider Demographics
NPI:1093777872
Name:MASHBURN FAMILY PRACTICE INC
Entity Type:Organization
Organization Name:MASHBURN FAMILY PRACTICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE SECRETARY/ OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:J
Authorized Official - Last Name:MASHBURN
Authorized Official - Suffix:
Authorized Official - Credentials:BSN RN
Authorized Official - Phone:330-482-0400
Mailing Address - Street 1:913 STATE ROUTE 46
Mailing Address - Street 2:OAKMONT PLAZA
Mailing Address - City:COLUMBIANA
Mailing Address - State:OH
Mailing Address - Zip Code:44408-9457
Mailing Address - Country:US
Mailing Address - Phone:330-482-0400
Mailing Address - Fax:330-482-0402
Practice Address - Street 1:913 STATE ROUTE 46
Practice Address - Street 2:OAKMONT PLAZA
Practice Address - City:COLUMBIANA
Practice Address - State:OH
Practice Address - Zip Code:44408-9457
Practice Address - Country:US
Practice Address - Phone:330-482-0400
Practice Address - Fax:330-482-0402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35075832207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2194889Medicaid
OHMA4018783Medicare ID - Type Unspecified
OHH14676Medicare UPIN