Provider Demographics
NPI:1831379643
Name:WEST AVENUE FAMILY PRACTICE, INC.
Entity type:Organization
Organization Name:WEST AVENUE FAMILY PRACTICE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:SCHMEISER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:330-633-8341
Mailing Address - Street 1:224 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:TALLMADGE
Mailing Address - State:OH
Mailing Address - Zip Code:44278-2110
Mailing Address - Country:US
Mailing Address - Phone:330-633-8341
Mailing Address - Fax:330-633-8462
Practice Address - Street 1:224 WEST AVE
Practice Address - Street 2:
Practice Address - City:TALLMADGE
Practice Address - State:OH
Practice Address - Zip Code:44278-2110
Practice Address - Country:US
Practice Address - Phone:330-633-8341
Practice Address - Fax:330-633-8462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-08
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34006905261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2289456Medicaid
4066762Medicare PIN
H54289Medicare UPIN