=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205053709
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHYSICIAN SERVICES OF OHIO LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2007
-----------------------------------------------------
Last Update Date | 07/24/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2527 MACNAUGHTEN ST NW
-----------------------------------------------------
City | NORTH CANTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44720-9529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-361-0908
-----------------------------------------------------
Fax | 330-305-6762
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2527 MACNAUGHTEN ST NW
-----------------------------------------------------
City | NORTH CANTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44720-9529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-361-0908
-----------------------------------------------------
Fax | 330-305-6762
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | JAVEDUL HAQUE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 330-361-0908
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 35081681
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------