=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902152366
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MASON FAMILY HEALTH CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2012
-----------------------------------------------------
Last Update Date | 01/14/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7808 DERBYSHIRE CT
-----------------------------------------------------
City | LIBERTY TOWNSHIP
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45044-9049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-204-2883
-----------------------------------------------------
Fax | 513-847-6317
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7808 DERBYSHIRE CT
-----------------------------------------------------
City | LIBERTY TOWNSHIP
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45044-9049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-204-2883
-----------------------------------------------------
Fax | 513-847-6317
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | JIGNESH PATEL
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 513-827-8700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | 35-097039
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------