=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588224745
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ASHLAND PRIMARY CARE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2019
-----------------------------------------------------
Last Update Date | 06/19/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1590 CRESTVIEW DR STE B
-----------------------------------------------------
City | ASHLAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44805-3560
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-651-6880
-----------------------------------------------------
Fax | 419-496-0306
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1590 CRESTVIEW DR STE B
-----------------------------------------------------
City | ASHLAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44805-3560
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-651-6880
-----------------------------------------------------
Fax | 419-496-0306
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD
-----------------------------------------------------
Name | JOHN T HANNA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 419-651-6880
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------