Provider Demographics
NPI:1245303221
Name:DAVIS FAMILY PRACTICE
Entity type:Organization
Organization Name:DAVIS FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SABRINA
Authorized Official - Middle Name:L
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:419-756-7500
Mailing Address - Street 1:390 MARION AVE
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44903-2015
Mailing Address - Country:US
Mailing Address - Phone:419-756-7500
Mailing Address - Fax:419-525-0001
Practice Address - Street 1:390 MARION AVE
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44903-2015
Practice Address - Country:US
Practice Address - Phone:419-756-7500
Practice Address - Fax:419-525-0001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH57229940400OtherBWC
OH2018613Medicaid
OH5240682OtherAETNA
OH000000213452OtherBLUE SHIELD
OH340069404001OtherMEDICAL MUTUAL
OH000000213452OtherBLUE SHIELD
OH57229940400OtherBWC