Provider Demographics
NPI:1568775054
Name:PARTNERS PHYSICIAN GROUP
Entity Type:Organization
Organization Name:PARTNERS PHYSICIAN GROUP
Other - Org Name:RICHFIELD PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR, FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:TAILLARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-344-6095
Mailing Address - Street 1:4336 BRECKSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44286-9195
Mailing Address - Country:US
Mailing Address - Phone:330-659-0641
Mailing Address - Fax:330-659-0649
Practice Address - Street 1:4336 BRECKSVILLE RD
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:OH
Practice Address - Zip Code:44286-9195
Practice Address - Country:US
Practice Address - Phone:330-659-0641
Practice Address - Fax:330-659-0649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-26
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2551671OtherPARTNERS PHYSICIAN GROUP MEDICAID GROUP #
OH1841239274OtherPARTNERS PHYSICIAN GROUP NPI GROUP #
OH9338635OtherPARTNERS PHYSICIAN GROUP MEDICARE GROUP #