Provider Demographics
NPI:1780870097
Name:CITY OF WASHINGTON INTERNAL MEDICINE, L.L.C.
Entity type:Organization
Organization Name:CITY OF WASHINGTON INTERNAL MEDICINE, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:W
Authorized Official - Last Name:HODGES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:740-333-6463
Mailing Address - Street 1:1450 COLUMBUS AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WASHINGTON COURT HOUSE
Mailing Address - State:OH
Mailing Address - Zip Code:43160-3701
Mailing Address - Country:US
Mailing Address - Phone:740-333-6463
Mailing Address - Fax:
Practice Address - Street 1:1450 COLUMBUS AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:WASHINGTON COURT HOUSE
Practice Address - State:OH
Practice Address - Zip Code:43160-3701
Practice Address - Country:US
Practice Address - Phone:740-333-6463
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-20
Last Update Date:2009-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35076874207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2883018Medicaid
OH9316211Medicare PIN
OH2883018Medicaid