Provider Demographics
NPI:1235304775
Name:PRIMESOURCE HEALTHCARE OF OHIO, INC
Entity Type:Organization
Organization Name:PRIMESOURCE HEALTHCARE OF OHIO, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:FLEMING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-267-8200
Mailing Address - Street 1:2100 EAST LAKE COOK ROAD
Mailing Address - Street 2:SUITE 1100
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-1815
Mailing Address - Country:US
Mailing Address - Phone:847-267-8200
Mailing Address - Fax:877-821-6402
Practice Address - Street 1:4449 EASTON WAY
Practice Address - Street 2:FLOOR 2
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43219-6093
Practice Address - Country:US
Practice Address - Phone:800-317-0711
Practice Address - Fax:877-821-6402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-25
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2719062Medicaid