Provider Demographics
NPI:1346417417
Name:CENTER STREET COMMUNITY CLINIC INC
Entity Type:Organization
Organization Name:CENTER STREET COMMUNITY CLINIC INC
Other - Org Name:CENTER STREET COMMUNITY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/EXECUTIVE DIRECTOR
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:740-751-6380
Mailing Address - Street 1:205 W CENTER ST
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:740-751-4189
Mailing Address - Fax:740-751-4866
Practice Address - Street 1:205 W CENTER ST
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:740-751-4189
Practice Address - Fax:740-751-4866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-08
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2859509Medicaid
OH361925Medicare Oscar/Certification