Healthcare Provider Details

I. General information

NPI: 1477959773
Provider Name (Legal Business Name): OHIO PODIATRIC PHYSICIANS AND SURGEONS GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2014
Last Update Date: 11/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1627 E MAIN ST
KENT OH
44240-2875
US

IV. Provider business mailing address

1627 E MAIN ST
KENT OH
44240-2875
US

V. Phone/Fax

Practice location:
  • Phone: 330-673-3505
  • Fax: 330-673-4888
Mailing address:
  • Phone: 330-673-3505
  • Fax: 330-673-4888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number36002148
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number36002148
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number36002148
License Number StateOH

VIII. Authorized Official

Name: DR. JAMES E BENEDICT
Title or Position: OWNER
Credential: DPM
Phone: 330-673-3505