Healthcare Provider Details

I. General information

NPI: 1699905851
Provider Name (Legal Business Name): PHYSICIAN'S MEDICAL CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2009
Last Update Date: 06/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

369 NILES CORTLAND RD SE
WARREN OH
44484-2430
US

IV. Provider business mailing address

369 NILES CORTLAND RD SE
WARREN OH
44484-2430
US

V. Phone/Fax

Practice location:
  • Phone: 330-856-9494
  • Fax: 330-856-1038
Mailing address:
  • Phone: 330-856-9494
  • Fax: 330-856-1038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number34007714
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 012820
License Number StateOH

VIII. Authorized Official

Name: MICHAEL C. MARTUCCIO
Title or Position: PRESIDENT
Credential:
Phone: 330-856-9494