Provider Demographics
NPI:1245532654
Name:PATRIO D TISMO PA INC
Entity type:Organization
Organization Name:PATRIO D TISMO PA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PATRIO
Authorized Official - Middle Name:D
Authorized Official - Last Name:TISMO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:740-532-0059
Mailing Address - Street 1:P.O. BOX 500
Mailing Address - Street 2:107 NORTH 3RD STREET
Mailing Address - City:IRONTON
Mailing Address - State:OH
Mailing Address - Zip Code:45638
Mailing Address - Country:US
Mailing Address - Phone:740-532-0059
Mailing Address - Fax:740-532-0380
Practice Address - Street 1:107 NORTH 3RD STREET
Practice Address - Street 2:
Practice Address - City:IRONTON
Practice Address - State:OH
Practice Address - Zip Code:45638
Practice Address - Country:US
Practice Address - Phone:740-532-0059
Practice Address - Fax:740-532-0380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-18
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33966207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0175706Medicaid
OHA73800Medicare UPIN
OHI0370165Medicare PIN