Provider Demographics
NPI:1639368350
Name:VIENNA MEDICAL ARTS CLINIC, INC
Entity Type:Organization
Organization Name:VIENNA MEDICAL ARTS CLINIC, INC
Other - Org Name:MARK E. DAVIS, D.O.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:E
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:330-394-2305
Mailing Address - Street 1:341 YOUNGSTOWN KINGSVILLE RD SE
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44473-9601
Mailing Address - Country:US
Mailing Address - Phone:330-394-2305
Mailing Address - Fax:330-394-1405
Practice Address - Street 1:341 YOUNGSTOWN KINGSVILLE RD SE
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:OH
Practice Address - Zip Code:44473-9601
Practice Address - Country:US
Practice Address - Phone:330-394-2305
Practice Address - Fax:330-394-1405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-18
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-004595207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2056260Medicaid
OH0797857Medicaid
OH0797857Medicaid
OH9372851Medicare PIN