Provider Demographics
NPI:1457384174
Name:OHIO HOSPITAL-BASED PHYSICIAN CORPORATION
Entity Type:Organization
Organization Name:OHIO HOSPITAL-BASED PHYSICIAN CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:FAITH
Authorized Official - Middle Name:
Authorized Official - Last Name:BASTIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-452-9911
Mailing Address - Street 1:2600 SIXTH STREET SW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44710
Mailing Address - Country:US
Mailing Address - Phone:330-452-9911
Mailing Address - Fax:
Practice Address - Street 1:2051 WALES RD NE
Practice Address - Street 2:
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44646-4111
Practice Address - Country:US
Practice Address - Phone:330-834-1111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2116589Medicaid
OH9301663Medicare PIN