Healthcare Provider Details

I. General information

NPI: 1609959931
Provider Name (Legal Business Name): NORTHEASTERN OHIO MEDICAL SPECIALISTS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 02/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

470 WHITE POND DR STE 100
AKRON OH
44320-1185
US

IV. Provider business mailing address

470 WHITE POND DR SUITE 100
AKRON OH
44320-1185
US

V. Phone/Fax

Practice location:
  • Phone: 330-869-8530
  • Fax: 330-869-8539
Mailing address:
  • Phone: 330-869-8530
  • Fax: 330-869-8539

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberNP67943
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35-07-3269-W
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35-07-3029M
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35-07-7486M
License Number StateOH

VIII. Authorized Official

Name: MS. SHANNON RAE SCOTT
Title or Position: ADMINISTRATIVE ASSISTANT
Credential: CMC
Phone: 330-869-8530