Provider Demographics
NPI:1205020104
Name:TRUMBULL MAHONING MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:TRUMBULL MAHONING MEDICAL GROUP, INC.
Other - Org Name:TMMG
Other - Org Type:Other Name
Authorized Official - Title/Position:PARTNER/EXECUTIVE
Authorized Official - Prefix:DR
Authorized Official - First Name:MOURAD
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSTOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-372-8820
Mailing Address - Street 1:2600 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:330-372-8800
Mailing Address - Fax:330-372-8999
Practice Address - Street 1:2600 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:330-372-8800
Practice Address - Fax:330-372-8999
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRUMBULL MAHONING MEDICAL GROUP, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-04
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0468677Medicaid
OH1426141OtherHIGHMARK BC/BS PA
OH000000243183OtherANTHEM BC/BS OHIO
OH0468677Medicaid
OH000000243183OtherANTHEM BC/BS OHIO
OH1426141OtherHIGHMARK BC/BS PA
OH=========-00OtherOHIO WORKERS COMP
OH=========001OtherTRICARE/HEALTHNET