Healthcare Provider Details

I. General information

NPI: 1508996539
Provider Name (Legal Business Name): ATHENS FAMILY PRACTICE CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 04/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 S SHAFER ST
ATHENS OH
45701-2351
US

IV. Provider business mailing address

101 S SHAFER ST
ATHENS OH
45701-2351
US

V. Phone/Fax

Practice location:
  • Phone: 740-592-4491
  • Fax: 740-592-4844
Mailing address:
  • Phone: 740-592-4491
  • Fax: 740-592-4844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MARK ROTHSTEIN
Title or Position: EXECUTIVE DIRECTOR
Credential: M.D.
Phone: 740-592-4491