Provider Demographics
NPI:1588636849
Name:FT RECOVERY FAMILY MEDICINE, INC
Entity Type:Organization
Organization Name:FT RECOVERY FAMILY MEDICINE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROHRER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-375-2122
Mailing Address - Street 1:807 BLUE JACKET DRIVE
Mailing Address - Street 2:
Mailing Address - City:FORT RECOVERY
Mailing Address - State:OH
Mailing Address - Zip Code:45846
Mailing Address - Country:US
Mailing Address - Phone:419-375-2122
Mailing Address - Fax:419-375-7003
Practice Address - Street 1:807 BLUE JACKET DRIVE
Practice Address - Street 2:
Practice Address - City:FORT RECOVERY
Practice Address - State:OH
Practice Address - Zip Code:45846
Practice Address - Country:US
Practice Address - Phone:419-375-2112
Practice Address - Fax:417-375-7003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-02
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH=========OtherFEDERAL TAX ID
OH=========-00OtherWORKER COMP CORPORATION
IN=========2ANOtherBLUE CROSS BLUE SHIELD
OH=========-00OtherWORKER COMP CORPORATION