Healthcare Provider Details

I. General information

NPI: 1427068634
Provider Name (Legal Business Name): STARK COUNTY MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 01/29/2024
Certification Date: 01/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4810 MUNSON ST NW
CANTON OH
44718-3613
US

IV. Provider business mailing address

4810 MUNSON ST NW
CANTON OH
44718-3613
US

V. Phone/Fax

Practice location:
  • Phone: 330-499-3377
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01397525
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01397525
License Number StateOH

VIII. Authorized Official

Name: CARRIE LYNN GILLSON
Title or Position: OFFICE MANAGER
Credential:
Phone: 330-499-3377