Provider Demographics
NPI:1609877687
Name:FIRST MEDICAL ASSOCIATES INC
Entity Type:Organization
Organization Name:FIRST MEDICAL ASSOCIATES INC
Other - Org Name:FIRST MEDICAL ASSOCIATES
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:NICHOLAS
Authorized Official - Last Name:DETESCO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-726-1138
Mailing Address - Street 1:7341 EISENHOWER DR
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-5900
Mailing Address - Country:US
Mailing Address - Phone:330-726-1138
Mailing Address - Fax:330-726-6128
Practice Address - Street 1:7341 EISENHOWER DR
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-5900
Practice Address - Country:US
Practice Address - Phone:330-726-1138
Practice Address - Fax:330-726-6128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-02
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35100173D207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0518470Medicaid
OH0518470Medicaid