Provider Demographics
NPI:1841752151
Name:PREVENTIVE MEDICINE GROUP INC
Entity Type:Organization
Organization Name:PREVENTIVE MEDICINE GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TAX ID OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:CASSELBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:440-995-0555
Mailing Address - Street 1:5555 MAYFIELD RD
Mailing Address - Street 2:
Mailing Address - City:LYNDHURST
Mailing Address - State:OH
Mailing Address - Zip Code:44124-2939
Mailing Address - Country:US
Mailing Address - Phone:440-995-0555
Mailing Address - Fax:440-995-1444
Practice Address - Street 1:5555 MAYFIELD RD
Practice Address - Street 2:
Practice Address - City:LYNDHURST
Practice Address - State:OH
Practice Address - Zip Code:44124-2939
Practice Address - Country:US
Practice Address - Phone:440-995-0555
Practice Address - Fax:440-995-1444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-04
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Single Specialty