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General NPI Number Information
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NPI Number | 1245532654
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Entity Type | Organization
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Legal Business Name | PATRIO D TISMO PA INC
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Dates
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Enumeration Date | 11/18/2010
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Last Update Date | 10/18/2011
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Provider Practice Location Address
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Address Line | 107 NORTH 3RD STREET
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City | IRONTON
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State | OH
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Zip | 45638
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Country | US
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Telephone | 740-532-0059
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Fax | 740-532-0380
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Provider Business Mailing Address
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Address Line | P.O. BOX 500 107 NORTH 3RD STREET
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City | IRONTON
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State | OH
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Zip | 45638
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Country | US
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Telephone | 740-532-0059
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Fax | 740-532-0380
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Authorized Official
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Title or Position | OWNER
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Name | PATRIO D TISMO
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Credential | M.D.
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Telephone | 740-532-0059
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 33966
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License Number State | OH
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