Healthcare Provider Details

I. General information

NPI: 1902095490
Provider Name (Legal Business Name): ALL AGES FAMILY MEDICINE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2007
Last Update Date: 10/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

241 PADDOCK CT
DELAWARE OH
43015-1317
US

IV. Provider business mailing address

241 PADDOCK CT
DELAWARE OH
43015-1317
US

V. Phone/Fax

Practice location:
  • Phone: 740-362-8686
  • Fax: 740-363-4662
Mailing address:
  • Phone: 740-362-8686
  • Fax: 740-363-4662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35076870H
License Number StateOH

VIII. Authorized Official

Name: DR. MARK A HICKMAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 740-362-8686