Provider Demographics
NPI:1174296172
Name:PIONEER PHYSICIANS NETWORK INC
Entity Type:Organization
Organization Name:PIONEER PHYSICIANS NETWORK INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING LIAISION
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:234-271-3353
Mailing Address - Street 1:3515 MASSILLON RD STE 300
Mailing Address - Street 2:
Mailing Address - City:UNIONTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44685-7854
Mailing Address - Country:US
Mailing Address - Phone:234-271-3353
Mailing Address - Fax:330-899-9267
Practice Address - Street 1:5454 FULTON DR NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-1727
Practice Address - Country:US
Practice Address - Phone:330-899-1051
Practice Address - Fax:330-634-1329
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-27
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0194267Medicaid