Healthcare Provider Details

I. General information

NPI: 1609123728
Provider Name (Legal Business Name): OHIOGUIDESTONE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2012
Last Update Date: 11/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 E BAGLEY RD
BEREA OH
44017-2058
US

IV. Provider business mailing address

434 EASTLAND ROAD
BEREA OH
44017-2058
US

V. Phone/Fax

Practice location:
  • Phone: 440-260-8379
  • Fax:
Mailing address:
  • Phone: 440-260-8327
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MANDY JACKSON
Title or Position: BILLING SUPERVISOR
Credential:
Phone: 440-260-8328