Provider Demographics
NPI:1346271608
Name:CENTER STREET COMMUNITY CLINIC INC
Entity Type:Organization
Organization Name:CENTER STREET COMMUNITY CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CLIFF
Authorized Official - Middle Name:G
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-375-6030
Mailing Address - Street 1:205 WEST CENTER STREET
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-3700
Mailing Address - Country:US
Mailing Address - Phone:740-375-6030
Mailing Address - Fax:740-382-8291
Practice Address - Street 1:205 WEST CENTER STREET
Practice Address - Street 2:SUITE 200
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-3700
Practice Address - Country:US
Practice Address - Phone:740-375-6030
Practice Address - Fax:740-382-8291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2807734Medicaid
OH9339281Medicare PIN
OHCE9339281Medicare ID - Type Unspecified