Provider Demographics
NPI:1740410521
Name:NORTHERN OHIO MEDICAL SPECIALISTS,LLC
Entity Type:Organization
Organization Name:NORTHERN OHIO MEDICAL SPECIALISTS,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:
Authorized Official - Last Name:FREDERICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-626-6161
Mailing Address - Street 1:PO BOX 378
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44871-0378
Mailing Address - Country:US
Mailing Address - Phone:419-609-1112
Mailing Address - Fax:419-502-3537
Practice Address - Street 1:15299 BAGLEY RD
Practice Address - Street 2:SUITE 100
Practice Address - City:MIDDLEBURG HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44130-4823
Practice Address - Country:US
Practice Address - Phone:440-885-2100
Practice Address - Fax:440-885-2106
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHERN OHIO MEDICAL SPECIALISTS,LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-15
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2253556Medicaid
OH2253556Medicaid
OH4258080009Medicare NSC