Provider Demographics
NPI:1972959534
Name:MAPLE CITY FAMILY PRACTICE, LLC
Entity Type:Organization
Organization Name:MAPLE CITY FAMILY PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:F
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-660-1717
Mailing Address - Street 1:1 E WILLARD AVE
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:OH
Mailing Address - Zip Code:44857-1155
Mailing Address - Country:US
Mailing Address - Phone:419-660-1717
Mailing Address - Fax:419-660-1718
Practice Address - Street 1:1 E WILLARD AVE
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:OH
Practice Address - Zip Code:44857-1155
Practice Address - Country:US
Practice Address - Phone:419-660-1717
Practice Address - Fax:419-660-1718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-12
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH35079818207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH52742Medicare UPIN