Healthcare Provider Details

I. General information

NPI: 1063078749
Provider Name (Legal Business Name): IMPACT PHYSICIAN GROUP, OHIO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2019
Last Update Date: 12/19/2022
Certification Date: 12/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23333 HARVARD RD
BEACHWOOD OH
44122-6232
US

IV. Provider business mailing address

21 EASTBROOK BND STE 218
PEACHTREE CITY GA
30269-1546
US

V. Phone/Fax

Practice location:
  • Phone: 216-593-2200
  • Fax:
Mailing address:
  • Phone: 678-967-5599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: PAUL MILLER
Title or Position: CEO
Credential:
Phone: 678-967-5599