Provider Demographics
NPI:1508996539
Name:ATHENS FAMILY PRACTICE CLINIC, INC
Entity Type:Organization
Organization Name:ATHENS FAMILY PRACTICE CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTHSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:740-592-4491
Mailing Address - Street 1:101 S SHAFER ST
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:OH
Mailing Address - Zip Code:45701-2351
Mailing Address - Country:US
Mailing Address - Phone:740-592-4491
Mailing Address - Fax:740-592-4844
Practice Address - Street 1:101 S SHAFER ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701-2351
Practice Address - Country:US
Practice Address - Phone:740-592-4491
Practice Address - Fax:740-592-4844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AT9157492Medicare ID - Type Unspecified
OH0349313Medicaid