Provider Demographics
NPI:1790955789
Name:SOUTHEASTERN OHIO AMBULATORY PHYSICIANS LLC
Entity Type:Organization
Organization Name:SOUTHEASTERN OHIO AMBULATORY PHYSICIANS LLC
Other - Org Name:VALLEY MEDCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KURT
Authorized Official - Middle Name:J
Authorized Official - Last Name:PALAZZO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-423-9862
Mailing Address - Street 1:809 FARSON AVE UNIT 101
Mailing Address - Street 2:
Mailing Address - City:BELPRE
Mailing Address - State:OH
Mailing Address - Zip Code:45714-1067
Mailing Address - Country:US
Mailing Address - Phone:740-423-9862
Mailing Address - Fax:740-423-9864
Practice Address - Street 1:809 FARSON AVE UNIT 101
Practice Address - Street 2:
Practice Address - City:BELPRE
Practice Address - State:OH
Practice Address - Zip Code:45714-1067
Practice Address - Country:US
Practice Address - Phone:740-423-9862
Practice Address - Fax:740-423-9864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-05
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35067200261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2224168Medicaid
OHSOSP04251OtherMEDICARE GROUP
OH4041832Medicare PIN
OHSOSP04251OtherMEDICARE GROUP