Provider Demographics
NPI:1780984211
Name:CENTER STREET COMMUNITY CLINIC INC
Entity type:Organization
Organization Name:CENTER STREET COMMUNITY CLINIC INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REVENUE CYCLE COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:A
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-751-4189
Mailing Address - Street 1:136 W CENTER ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-3704
Mailing Address - Country:US
Mailing Address - Phone:740-751-6380
Mailing Address - Fax:740-751-4866
Practice Address - Street 1:136 W CENTER ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-3704
Practice Address - Country:US
Practice Address - Phone:740-751-6380
Practice Address - Fax:740-751-4866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-01
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3148061Medicaid
OH1780984211OtherNPI
OH3148061Medicaid