Provider Demographics
NPI:1821170911
Name:SAM N GHOUBRIAL MD INC
Entity Type:Organization
Organization Name:SAM N GHOUBRIAL MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:PELFREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-331-7207
Mailing Address - Street 1:3535 GRANGER RD
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44333-1538
Mailing Address - Country:US
Mailing Address - Phone:330-331-7207
Mailing Address - Fax:330-331-7587
Practice Address - Street 1:195 WADSWORTH RD.
Practice Address - Street 2:SUITE 402
Practice Address - City:WADSWORTH
Practice Address - State:OH
Practice Address - Zip Code:44281
Practice Address - Country:US
Practice Address - Phone:330-331-7207
Practice Address - Fax:330-331-7587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 207R00000X
OH35067926207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2683298Medicaid
OH9351571Medicare PIN