=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548511504
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. MILDRED LUCILLE SAGOWITZ
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/30/2012
-----------------------------------------------------
Last Update Date | 09/30/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 325 HUDSON AVE APT A
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43055-5787
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-975-7231
-----------------------------------------------------
Fax | 740-281-0028
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 325 HUDSON AVE APT A
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43055-5787
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-975-7231
-----------------------------------------------------
Fax | 740-281-0028
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | PN117118
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------