Provider Demographics
NPI:1689695652
Name:AULTMAN HEALTH FOUNDATION
Entity Type:Organization
Organization Name:AULTMAN HEALTH FOUNDATION
Other - Org Name:AULTMAN HOSPITAL URGENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:G SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDONOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-834-1111
Mailing Address - Street 1:6100 WHIPPLE AVE NW
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-7618
Mailing Address - Country:US
Mailing Address - Phone:330-305-6999
Mailing Address - Fax:330-305-6997
Practice Address - Street 1:6100 WHIPPLE AVE NW
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-7618
Practice Address - Country:US
Practice Address - Phone:330-305-6999
Practice Address - Fax:330-305-6997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OH0210516003336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2113859Medicaid
3674428OtherNCPDP PROVIDER IDENTIFICATION NUMBER