Provider Demographics
NPI:1275863896
Name:OPEN AWARENESS MEDICAL LLC
Entity Type:Organization
Organization Name:OPEN AWARENESS MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:W
Authorized Official - Last Name:MCCLELLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-339-9000
Mailing Address - Street 1:875 BLAKE AVE SW
Mailing Address - Street 2:SUITE #2
Mailing Address - City:NEW PHILADELPHIA
Mailing Address - State:OH
Mailing Address - Zip Code:44663-9338
Mailing Address - Country:US
Mailing Address - Phone:330-339-9000
Mailing Address - Fax:330-339-1122
Practice Address - Street 1:875 BLAKE AVE SW
Practice Address - Street 2:SUITE #2
Practice Address - City:NEW PHILADELPHIA
Practice Address - State:OH
Practice Address - Zip Code:44663-9338
Practice Address - Country:US
Practice Address - Phone:330-339-9000
Practice Address - Fax:330-339-1122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-04
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0340929Medicaid
OH9388531Medicare PIN