Provider Demographics
NPI:1346422425
Name:SYLVAN LAKES FAMILY PHYSICIANS LTD
Entity Type:Organization
Organization Name:SYLVAN LAKES FAMILY PHYSICIANS LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:H
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-517-1001
Mailing Address - Street 1:7640 SYLVANIA AVE
Mailing Address - Street 2:SUITE K
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-9729
Mailing Address - Country:US
Mailing Address - Phone:419-517-1001
Mailing Address - Fax:419-517-1021
Practice Address - Street 1:7640 SYLVANIA AVE
Practice Address - Street 2:SUITE K
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-9729
Practice Address - Country:US
Practice Address - Phone:419-517-1001
Practice Address - Fax:419-517-1021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-30
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2516503Medicaid
OHDC0712OtherRAILROAD MEDICARE
OH9345731Medicare PIN