Provider Demographics
NPI:1336319060
Name:PROSPECT ROAD FAMILY PRACTICE
Entity Type:Organization
Organization Name:PROSPECT ROAD FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIK
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:BERNHOFFER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-393-2593
Mailing Address - Street 1:9765 E PROSPECT RD
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45133-9084
Mailing Address - Country:US
Mailing Address - Phone:937-393-2593
Mailing Address - Fax:937-393-2939
Practice Address - Street 1:9765 E PROSPECT RD
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OH
Practice Address - Zip Code:45133-9084
Practice Address - Country:US
Practice Address - Phone:937-393-2593
Practice Address - Fax:937-393-2939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-10
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35066504207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHG04178Medicare UPIN