Provider Demographics
NPI:1356432926
Name:M & K FAMILY AND SPORTS MEDICINE, INC.
Entity type:Organization
Organization Name:M & K FAMILY AND SPORTS MEDICINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:A
Authorized Official - Last Name:MANSFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-538-7330
Mailing Address - Street 1:PO BOX 81
Mailing Address - Street 2:
Mailing Address - City:GLANDORF
Mailing Address - State:OH
Mailing Address - Zip Code:45848-0081
Mailing Address - Country:US
Mailing Address - Phone:419-538-7330
Mailing Address - Fax:419-538-7331
Practice Address - Street 1:601 US 224
Practice Address - Street 2:
Practice Address - City:GLANDORF
Practice Address - State:OH
Practice Address - Zip Code:45848
Practice Address - Country:US
Practice Address - Phone:419-538-7330
Practice Address - Fax:419-538-7331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DF2023OtherMEDICARE RAILROAD GROUP
OH2986729Medicaid
OH9364531Medicare PIN