Provider Demographics
NPI:1104038595
Name:FAMILY PRACTICE WEST INC
Entity Type:Organization
Organization Name:FAMILY PRACTICE WEST INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JIMILEA
Authorized Official - Middle Name:
Authorized Official - Last Name:GUTHEIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-878-7285
Mailing Address - Street 1:5212 W BROAD ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43228-1642
Mailing Address - Country:US
Mailing Address - Phone:614-878-7285
Mailing Address - Fax:614-878-1724
Practice Address - Street 1:5212 W BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43228-1642
Practice Address - Country:US
Practice Address - Phone:614-878-7285
Practice Address - Fax:614-878-1724
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-05
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34008162207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2649076Medicaid
OH2649076Medicaid