=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518156074
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TUSC COUNTY MEDICAL SPECIALTIES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2007
-----------------------------------------------------
Last Update Date | 01/06/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 MEDICAL PARK DR SUITE 205
-----------------------------------------------------
City | DOVER
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44622-2073
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-364-4600
-----------------------------------------------------
Fax | 330-364-3338
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 300 MEDICAL PARK DR SUITE 205
-----------------------------------------------------
City | DOVER
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44622-2073
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-364-4600
-----------------------------------------------------
Fax | 330-364-3338
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | M.D.
-----------------------------------------------------
Name | DR. BLAIR THOMAS HOLDER
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 330-364-4600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 55408
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------