Provider Demographics
NPI:1669453189
Name:NORTHRIDGE FAMILY PRACTICE LLC
Entity Type:Organization
Organization Name:NORTHRIDGE FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:LEA
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-474-3159
Mailing Address - Street 1:610 NORTHRIDGE RD
Mailing Address - Street 2:PO BOX 578
Mailing Address - City:CIRCLEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43113
Mailing Address - Country:US
Mailing Address - Phone:740-474-3159
Mailing Address - Fax:740-474-2110
Practice Address - Street 1:610 NORTHRIDGE RD
Practice Address - Street 2:
Practice Address - City:CIRCLEVILLE
Practice Address - State:OH
Practice Address - Zip Code:43113
Practice Address - Country:US
Practice Address - Phone:740-474-3159
Practice Address - Fax:740-474-2110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-10
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35042158B207Q00000X
OH35053974M207Q00000X
OH350463858207Q00000X
OH35071002J207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2211430Medicaid
OH2211430Medicaid