Healthcare Provider Details

I. General information

NPI: 1083828974
Provider Name (Legal Business Name): FOUNDATION HEALTH CARE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 02/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6615 CLINGAN ROAD SUITE A
POLAND OH
44514
US

IV. Provider business mailing address

6615 CLINGAN ROAD SUITE A
POLAND OH
44514
US

V. Phone/Fax

Practice location:
  • Phone: 330-707-1425
  • Fax: 330-757-2814
Mailing address:
  • Phone: 330-707-1425
  • Fax: 330-757-2814

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35-04-7881
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number34-00-5052
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35-08-6492
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35-049373
License Number StateOH

VIII. Authorized Official

Name: MICHAEL B EVAN
Title or Position: PRESIDENT
Credential: MD
Phone: 330-707-1425