=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003092495
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TINA NELSON MD & ASSOCIATES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2008
-----------------------------------------------------
Last Update Date | 04/23/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3477 COMMERCE PKWY SUITE A
-----------------------------------------------------
City | WOOSTER
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44691-7126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-345-8410
-----------------------------------------------------
Fax | 330-345-8458
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3477 COMMERCE PKWY SUITE A
-----------------------------------------------------
City | WOOSTER
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44691-7126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-345-8410
-----------------------------------------------------
Fax | 330-345-8458
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS MANAGER
-----------------------------------------------------
Name | RUSSELL W NELSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 330-345-8410
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------