Provider Demographics
NPI:1255521514
Name:NORTHERN OHIO MEDICAL SPECIALISTS
Entity type:Organization
Organization Name:NORTHERN OHIO MEDICAL SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:P
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-626-6161
Mailing Address - Street 1:521 N SANDUSKY ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:BELLEVUE
Mailing Address - State:OH
Mailing Address - Zip Code:44811-1180
Mailing Address - Country:US
Mailing Address - Phone:419-483-6267
Mailing Address - Fax:419-483-1614
Practice Address - Street 1:521 N SANDUSKY ST
Practice Address - Street 2:SUITE B
Practice Address - City:BELLEVUE
Practice Address - State:OH
Practice Address - Zip Code:44811-1180
Practice Address - Country:US
Practice Address - Phone:419-483-6267
Practice Address - Fax:419-483-1614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-01
Last Update Date:2009-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35059687207K00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2807289Medicaid
OH2807289Medicaid