Provider Demographics
NPI:1376287268
Name:ADVANCED FAMILY MEDICINE LLC
Entity Type:Organization
Organization Name:ADVANCED FAMILY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:CAMERON
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:614-875-0079
Mailing Address - Street 1:4160 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43123-3024
Mailing Address - Country:US
Mailing Address - Phone:614-594-3080
Mailing Address - Fax:
Practice Address - Street 1:4160 BROADWAY
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:OH
Practice Address - Zip Code:43123-3024
Practice Address - Country:US
Practice Address - Phone:614-594-3080
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-26
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0800XAmbulatory Health Care FacilitiesClinic/CenterRecovery Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH01-8755OtherOHIO DEPARTMENT OF MENTAL HEALTH