Provider Demographics
NPI:1649453754
Name:DOCTORS FAMILY PRACTICE GROUP
Entity type:Organization
Organization Name:DOCTORS FAMILY PRACTICE GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BENEDICTA
Authorized Official - Middle Name:O
Authorized Official - Last Name:UDEAGBALA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:614-322-6063
Mailing Address - Street 1:PO BOX 785
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-0785
Mailing Address - Country:US
Mailing Address - Phone:614-322-6063
Mailing Address - Fax:614-322-9710
Practice Address - Street 1:6543 E MAIN ST
Practice Address - Street 2:SUITE C
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-2429
Practice Address - Country:US
Practice Address - Phone:614-322-6063
Practice Address - Fax:614-322-9710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-12
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH6079261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0241812Medicaid
OHSP00091Medicare PIN