=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487895967
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROSPECT FAMILY MEDICINE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2009
-----------------------------------------------------
Last Update Date | 05/17/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 102 WATER STREET
-----------------------------------------------------
City | PROSPECT
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43342
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-494-2624
-----------------------------------------------------
Fax | 740-494-9013
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 102 E WATER STREET POST OFFICE BOX 203
-----------------------------------------------------
City | PROSPECT
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43342-0203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-494-2624
-----------------------------------------------------
Fax | 740-494-9013
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. MARK JOHN PIACENTINI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 740-494-2624
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 35054820P
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------