Provider Demographics
NPI:1659646628
Name:MOUNT CARMEL HEALTHPROVIDERS III, LLC
Entity Type:Organization
Organization Name:MOUNT CARMEL HEALTHPROVIDERS III, LLC
Other - Org Name:MOUNT CARMEL HEALTH STATIONS REYNOLDSBURG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:HANCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-546-4621
Mailing Address - Street 1:6699 E LIVINGSTON AVE
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-3688
Mailing Address - Country:US
Mailing Address - Phone:614-367-1255
Mailing Address - Fax:614-367-1265
Practice Address - Street 1:6699 E LIVINGSTON AVE
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-3688
Practice Address - Country:US
Practice Address - Phone:614-367-1255
Practice Address - Fax:614-367-1265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-09
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty