Healthcare Provider Details

I. General information

NPI: 1801377833
Provider Name (Legal Business Name): FAMILY MEDICINE & ADULT CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2018
Last Update Date: 08/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2330 E HIGH ST
SPRINGFIELD OH
45505-1371
US

IV. Provider business mailing address

2631 WYNDHAM DR
BEAVERCREEK OH
45431-8539
US

V. Phone/Fax

Practice location:
  • Phone: 937-505-9501
  • Fax: 937-505-6172
Mailing address:
  • Phone: 614-747-3220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MTANIOUS MAKHOUL
Title or Position: PRESIDENT
Credential: MD
Phone: 614-747-3220