Provider Demographics
NPI:1962447227
Name:PRIMARY HEALTH CARE OF ASHTABULA, INC
Entity Type:Organization
Organization Name:PRIMARY HEALTH CARE OF ASHTABULA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-563-5028
Mailing Address - Street 1:5266 STATE ROUTE 45
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:OH
Mailing Address - Zip Code:44085-9404
Mailing Address - Country:US
Mailing Address - Phone:440-563-5028
Mailing Address - Fax:440-563-3044
Practice Address - Street 1:5266 STATE ROUTE 45
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:OH
Practice Address - Zip Code:44085-9404
Practice Address - Country:US
Practice Address - Phone:440-563-5028
Practice Address - Fax:440-563-3044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2218906Medicaid
OH4116471Medicare PIN
OH2218906Medicaid
OH363838Medicare PIN