Provider Demographics
NPI:1245273911
Name:AFFINITY FAMILY PRACTICE CENTER
Entity type:Organization
Organization Name:AFFINITY FAMILY PRACTICE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANGER
Authorized Official - Prefix:
Authorized Official - First Name:BECKY
Authorized Official - Middle Name:J
Authorized Official - Last Name:DURBIN
Authorized Official - Suffix:
Authorized Official - Credentials:OFFICE MANGER
Authorized Official - Phone:330-682-3075
Mailing Address - Street 1:365 S CROWN HILL RD
Mailing Address - Street 2:
Mailing Address - City:ORRVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44667-9527
Mailing Address - Country:US
Mailing Address - Phone:330-682-3075
Mailing Address - Fax:330-682-7454
Practice Address - Street 1:365 S CROWN HILL RD
Practice Address - Street 2:
Practice Address - City:ORRVILLE
Practice Address - State:OH
Practice Address - Zip Code:44667-9527
Practice Address - Country:US
Practice Address - Phone:330-682-3075
Practice Address - Fax:330-682-7454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34008128207Q00000X
OH34008892207Q00000X
OH34002743204D00000X
OH34006265207Q00000X
OH34002356207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2876339Medicaid
OH0443765Medicaid
OH0241616Medicaid
OH0284697Medicaid