Provider Demographics
NPI:1104823889
Name:MANSFIELD FAMILY PRACTICE
Entity Type:Organization
Organization Name:MANSFIELD FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-524-2212
Mailing Address - Street 1:248 BLYMYER AVE
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44903-2306
Mailing Address - Country:US
Mailing Address - Phone:419-524-2212
Mailing Address - Fax:419-524-9040
Practice Address - Street 1:248 BLYMYER AVE
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44903-2306
Practice Address - Country:US
Practice Address - Phone:419-524-2212
Practice Address - Fax:419-524-9040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2261234Medicaid
OH2261234Medicaid