Provider Demographics
NPI:1801189592
Name:DR. DIRK LLC
Entity Type:Organization
Organization Name:DR. DIRK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DIRK
Authorized Official - Middle Name:NORMAN
Authorized Official - Last Name:JUSCHKA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-402-1000
Mailing Address - Street 1:PO BOX 609
Mailing Address - Street 2:
Mailing Address - City:LUCASVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45648-0609
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 W SPRING ST UNIT 702
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-7651
Practice Address - Country:US
Practice Address - Phone:937-232-8033
Practice Address - Fax:937-426-6576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-27
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207QG0300X
OH35.052815314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0616033Medicaid
OH0616033Medicaid