=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346422425
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SYLVAN LAKES FAMILY PHYSICIANS LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2007
-----------------------------------------------------
Last Update Date | 02/04/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7640 SYLVANIA AVE SUITE K
-----------------------------------------------------
City | SYLVANIA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43560-9729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-517-1001
-----------------------------------------------------
Fax | 419-517-1021
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7640 SYLVANIA AVE SUITE K
-----------------------------------------------------
City | SYLVANIA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43560-9729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-517-1001
-----------------------------------------------------
Fax | 419-517-1021
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. PHILLIP H FISHER
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 419-517-1001
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------