Provider Demographics
NPI:1104835743
Name:PERRY COUNTY FAMILY PRACTICE, INC.
Entity Type:Organization
Organization Name:PERRY COUNTY FAMILY PRACTICE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SOCIAL WORKER
Authorized Official - Prefix:MRS
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:L
Authorized Official - Last Name:ULRICH
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LISW
Authorized Official - Phone:740-342-5158
Mailing Address - Street 1:1625 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:NEW LEXINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43764-9749
Mailing Address - Country:US
Mailing Address - Phone:740-342-5158
Mailing Address - Fax:740-342-7393
Practice Address - Street 1:1625 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:NEW LEXINGTON
Practice Address - State:OH
Practice Address - Zip Code:43764-9749
Practice Address - Country:US
Practice Address - Phone:740-342-5158
Practice Address - Fax:740-342-7393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-042516261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0648580Medicaid
OH0940996Medicaid
OH9922772Medicare ID - Type UnspecifiedMEDICARE GRP#-ZANESVILLE
363829Medicare Oscar/Certification
OH0940996Medicaid