Healthcare Provider Details

I. General information

NPI: 1285642769
Provider Name (Legal Business Name): TRUMBULL MAHONING MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 01/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 ELM RD NE
CORTLAND OH
44410-9393
US

IV. Provider business mailing address

2600 ELM RD NE
CORTLAND OH
44410-9393
US

V. Phone/Fax

Practice location:
  • Phone: 330-372-8800
  • Fax: 330-372-8999
Mailing address:
  • Phone: 330-372-8800
  • Fax: 330-372-8999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MOURAD ROSTOM
Title or Position: PRESIDENT/CEO
Credential: M.D.
Phone: 330-372-8820