=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811910813
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AULTMAN HEALTH FOUNDATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2006
-----------------------------------------------------
Last Update Date | 04/19/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2021 WALES AVE NW
-----------------------------------------------------
City | MASSILLON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44646
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-305-6999
-----------------------------------------------------
Fax | 330-830-5454
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2021 WALES AVE NW
-----------------------------------------------------
City | MASSILLON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44646
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-305-6999
-----------------------------------------------------
Fax | 330-830-5454
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | G SCOTT MCDONOUGH
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 330-834-1111
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0002X
-----------------------------------------------------
Taxonomy Name | Clinic Pharmacy
-----------------------------------------------------
License Number | CL.021021550-03
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------