Healthcare Provider Details

I. General information

NPI: 1497717664
Provider Name (Legal Business Name): HEALTHRIDGE MEDICAL CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2006
Last Update Date: 12/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 STRUTHERS LIBERTY RD
CAMPBELL OH
44405-1949
US

IV. Provider business mailing address

315 STRUTHERS LIBERTY RD
CAMPBELL OH
44405-1949
US

V. Phone/Fax

Practice location:
  • Phone: 330-750-1333
  • Fax: 330-750-0203
Mailing address:
  • Phone: 330-750-1333
  • Fax: 330-750-0203

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
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MS. VICKI LYNN MILLER
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 330-750-1333