Provider Demographics
NPI:1417139338
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:MR
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:614-875-0079
Mailing Address - Fax:614-875-2008
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:614-875-0079
Practice Address - Fax:614-875-2008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-03
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34007672J207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH85208Medicare UPIN