Provider Demographics
NPI:1477889533
Name:NORTHERN OHIO MEDICAL SPECIALISTS
Entity Type:Organization
Organization Name:NORTHERN OHIO MEDICAL SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:P
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-626-6161
Mailing Address - Street 1:PO BOX 363741
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-0001
Mailing Address - Country:US
Mailing Address - Phone:419-609-1112
Mailing Address - Fax:419-609-1123
Practice Address - Street 1:224 W LORAIN ST
Practice Address - Street 2:SUITE C
Practice Address - City:OBERLIN
Practice Address - State:OH
Practice Address - Zip Code:44074-1096
Practice Address - Country:US
Practice Address - Phone:440-776-7009
Practice Address - Fax:440-776-7096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-26
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2253556Medicaid
OH9313601Medicare PIN