Provider Demographics
NPI:1114968849
Name:FORUM HEALTH SERVICES
Entity Type:Organization
Organization Name:FORUM HEALTH SERVICES
Other - Org Name:ELM ROAD IMMEDIATE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:NIEMI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-841-3004
Mailing Address - Street 1:2662 ELM RD NE
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44410-9393
Mailing Address - Country:US
Mailing Address - Phone:330-841-3004
Mailing Address - Fax:
Practice Address - Street 1:2662 ELM RD NE
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:OH
Practice Address - Zip Code:44410-9393
Practice Address - Country:US
Practice Address - Phone:330-841-3004
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH94930OtherQUALCHOICE NUMBER
OH000000165909OtherANTHEM GROUP NUMBER
OH6600170OtherUHC PROV NUMBER
OH7997187OtherAETNA GROUP NUMBER
OH1525808OtherGATEWAY GROUP NUMBER
OH2179913Medicaid
OH94930OtherQUALCHOICE NUMBER
OH=========-038OtherCARESOURCE PROV NUMBER
OH9292572Medicare ID - Type UnspecifiedGROUP NUMBER