Provider Demographics
NPI:1184794885
Name:EXECUTIVE COURT MEDICAL ASSOCIATES INC.
Entity type:Organization
Organization Name:EXECUTIVE COURT MEDICAL ASSOCIATES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:GRAHAM
Authorized Official - Middle Name:M
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:CMOM
Authorized Official - Phone:419-668-5607
Mailing Address - Street 1:54 EXECUTIVE DR
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:OH
Mailing Address - Zip Code:44857-9566
Mailing Address - Country:US
Mailing Address - Phone:419-668-5607
Mailing Address - Fax:419-668-9706
Practice Address - Street 1:54 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:OH
Practice Address - Zip Code:44857-9566
Practice Address - Country:US
Practice Address - Phone:419-668-5607
Practice Address - Fax:419-668-9706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH842075Medicaid
OH9260471Medicare PIN
OH9260472Medicare PIN