Provider Demographics
NPI:1770609745
Name:MINGO MEDICAL GROUP
Entity type:Organization
Organization Name:MINGO MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:E
Authorized Official - Last Name:JOHNS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:740-535-0555
Mailing Address - Street 1:201 MCLISTER AVE
Mailing Address - Street 2:
Mailing Address - City:MINGO JUNCTION
Mailing Address - State:OH
Mailing Address - Zip Code:43938-1260
Mailing Address - Country:US
Mailing Address - Phone:740-535-0555
Mailing Address - Fax:740-535-2020
Practice Address - Street 1:201 MCLISTER AVE
Practice Address - Street 2:
Practice Address - City:MINGO JUNCTION
Practice Address - State:OH
Practice Address - Zip Code:43938-1260
Practice Address - Country:US
Practice Address - Phone:740-535-0555
Practice Address - Fax:740-535-2020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35041816J207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0446664Medicaid
OH0446664Medicaid
OH9916061Medicare PIN