Healthcare Provider Details

I. General information

NPI: 1164664124
Provider Name (Legal Business Name): GEORGE PAPACOSTAS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2009
Last Update Date: 03/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 6TH STREET SW AULTMAN WOUND CARE CENTER
CANTON OH
44710
US

IV. Provider business mailing address

3206 20TH ST NW
CANTON OH
44708-2918
US

V. Phone/Fax

Practice location:
  • Phone: 330-363-4977
  • Fax:
Mailing address:
  • Phone: 330-495-5719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number35084670
License Number StateOH

VIII. Authorized Official

Name: GEORGE PAPACOSTAS
Title or Position: PRESIDENT
Credential: MD
Phone: 330-495-5719