Healthcare Provider Details

I. General information

NPI: 1881706091
Provider Name (Legal Business Name): GRANT/RIVERSIDE MEDICAL CARE FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 07/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11925 LITHOPOLIS RD NW TRICOUNTY FAMILY MEDICINE
CANAL WINCHESTER OH
43110-9585
US

IV. Provider business mailing address

5350 FRANTZ RD
DUBLIN OH
43016-4259
US

V. Phone/Fax

Practice location:
  • Phone: 614-837-6363
  • Fax: 614-837-0425
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: TRACY HEDGES
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 614-544-6356