Provider Demographics
NPI:1366642498
Name:JAMES P. FRACKELTON, MD, INC
Entity Type:Organization
Organization Name:JAMES P. FRACKELTON, MD, INC
Other - Org Name:PREVENTIVE MEDICINE GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WENGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-835-2150
Mailing Address - Street 1:24700 CENTER RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-5636
Mailing Address - Country:US
Mailing Address - Phone:440-835-0104
Mailing Address - Fax:440-835-2177
Practice Address - Street 1:24700 CENTER RIDGE RD
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-5636
Practice Address - Country:US
Practice Address - Phone:440-835-0104
Practice Address - Fax:440-835-2177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-18
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPR9238811Medicare PIN