Provider Demographics
NPI:1013980044
Name:MEDCORP OF STARK COUNTY, INC.
Entity Type:Organization
Organization Name:MEDCORP OF STARK COUNTY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:D
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-833-8996
Mailing Address - Street 1:2500 WALES AVE NW
Mailing Address - Street 2:
Mailing Address - City:MASSILLON
Mailing Address - State:OH
Mailing Address - Zip Code:44646-2324
Mailing Address - Country:US
Mailing Address - Phone:330-833-8996
Mailing Address - Fax:330-833-6969
Practice Address - Street 1:2500 WALES AVE NW
Practice Address - Street 2:
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44646-2324
Practice Address - Country:US
Practice Address - Phone:330-833-8996
Practice Address - Fax:330-833-6969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-09
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0559908Medicaid
OH9918911OtherMEDICARE ID NUMBER