Provider Demographics
NPI:1629190921
Name:BEREA FAMILY MEDICINE, INC
Entity Type:Organization
Organization Name:BEREA FAMILY MEDICINE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARY ELLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WIGGENHORN
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:440-234-0502
Mailing Address - Street 1:853 W BAGLEY RD
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:OH
Mailing Address - Zip Code:44017-2903
Mailing Address - Country:US
Mailing Address - Phone:440-234-0502
Mailing Address - Fax:440-234-0590
Practice Address - Street 1:853 W BAGLEY RD
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:OH
Practice Address - Zip Code:44017-2903
Practice Address - Country:US
Practice Address - Phone:440-234-0502
Practice Address - Fax:440-234-0590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35049545207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2849172Medicaid
N09340931Medicare PIN