Provider Demographics
NPI:1225080591
Name:SUPERIOR MED LLC
Entity Type:Organization
Organization Name:SUPERIOR MED LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:JEVAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-435-2404
Mailing Address - Street 1:1251 CLARK ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:OH
Mailing Address - Zip Code:43725-9612
Mailing Address - Country:US
Mailing Address - Phone:740-439-0733
Mailing Address - Fax:740-439-8996
Practice Address - Street 1:10095 BRICK CHURCH RD
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:OH
Practice Address - Zip Code:43725-8550
Practice Address - Country:US
Practice Address - Phone:740-435-4022
Practice Address - Fax:740-435-4028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0915013Medicaid
OH9247358Medicare UPIN
OHSU9247351Medicare ID - Type Unspecified