Provider Demographics
NPI:1609959931
Name:NORTHEASTERN OHIO MEDICAL SPECIALISTS INC
Entity Type:Organization
Organization Name:NORTHEASTERN OHIO MEDICAL SPECIALISTS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:CMC
Authorized Official - Phone:330-869-8530
Mailing Address - Street 1:470 WHITE POND DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44320-1185
Mailing Address - Country:US
Mailing Address - Phone:330-869-8530
Mailing Address - Fax:330-869-8539
Practice Address - Street 1:470 WHITE POND DR STE 100
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44320-1185
Practice Address - Country:US
Practice Address - Phone:330-869-8530
Practice Address - Fax:330-869-8539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-07-3269-W207Q00000X
OH35-07-7486M207R00000X
OH35-07-3029M207R00000X
OHNP67943363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2269147Medicaid
OH9317331Medicare ID - Type Unspecified