Healthcare Provider Details

I. General information

NPI: 1235304775
Provider Name (Legal Business Name): PRIMESOURCE HEALTHCARE OF OHIO, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2008
Last Update Date: 10/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4449 EASTON WAY FLOOR 2
COLUMBUS OH
43219-6093
US

IV. Provider business mailing address

2100 EAST LAKE COOK ROAD SUITE 1100
BUFFALO GROVE IL
60089-1815
US

V. Phone/Fax

Practice location:
  • Phone: 800-317-0711
  • Fax: 877-821-6402
Mailing address:
  • Phone: 847-267-8200
  • Fax: 877-821-6402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: MR. DAVID FLEMING
Title or Position: PRESIDENT & CEO
Credential:
Phone: 847-267-8200