Provider Demographics
NPI:1649599408
Name:GOOD SHEPHERD FAMILY& GERIATRIAC MEDICAL CENTER INC
Entity Type:Organization
Organization Name:GOOD SHEPHERD FAMILY& GERIATRIAC MEDICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KAMAL
Authorized Official - Middle Name:NT
Authorized Official - Last Name:YOAKIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-854-2515
Mailing Address - Street 1:344 EMBER DR
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:OH
Mailing Address - Zip Code:43616-1716
Mailing Address - Country:US
Mailing Address - Phone:630-854-2515
Mailing Address - Fax:419-740-7288
Practice Address - Street 1:1661 HOLLAND RD
Practice Address - Street 2:
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-4207
Practice Address - Country:US
Practice Address - Phone:630-854-2515
Practice Address - Fax:419-740-7288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-19
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35093757261QF0050X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0050XAmbulatory Health Care FacilitiesClinic/CenterFamily Planning, Non-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3043030Medicaid