Provider Demographics
NPI:1932156742
Name:MARYSVILLE PRIMARY CARE, INC
Entity Type:Organization
Organization Name:MARYSVILLE PRIMARY CARE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:BETH
Authorized Official - Middle Name:L
Authorized Official - Last Name:BRAKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-644-1441
Mailing Address - Street 1:1044 COLUMBUS AVE
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040-8337
Mailing Address - Country:US
Mailing Address - Phone:937-644-1441
Mailing Address - Fax:937-642-7760
Practice Address - Street 1:1044 COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040-8337
Practice Address - Country:US
Practice Address - Phone:937-644-1441
Practice Address - Fax:937-642-7760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35073238M207K00000X, 207R00000X, 208000000X
OH58625207Q00000X
OH57093207R00000X, 208000000X
OHRN215818363LF0000X
OHRN186421363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Not Answered363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH=========OtherTAX ID #