=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245251271
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WALZ FAMILY MEDICINE, P.S.C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2006
-----------------------------------------------------
Last Update Date | 03/19/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 ASHLAND DR SUITE 105
-----------------------------------------------------
City | ASHLAND
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41101-7084
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-327-0077
-----------------------------------------------------
Fax | 606-833-9453
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 936
-----------------------------------------------------
City | FLATWOODS
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41139-0936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-327-0077
-----------------------------------------------------
Fax | 606-833-9453
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | DR. JON H. WALZ JR.
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 606-327-0077
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 02629
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------