=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912138157
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GOOD SHEPHERD COMMUNITY DOCTORS OFFICE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2009
-----------------------------------------------------
Last Update Date | 08/05/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30 W FRONT ST
-----------------------------------------------------
City | YOUNGSTOWN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44503-1417
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-782-2800
-----------------------------------------------------
Fax | 330-746-2855
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30 W FRONT ST
-----------------------------------------------------
City | YOUNGSTOWN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44503-1417
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-782-2800
-----------------------------------------------------
Fax | 330-746-2855
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MRS. YVETTE ETNA THORNTON
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 330-782-2800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QC1500X
-----------------------------------------------------
Taxonomy Name | Community Health Clinic/Center
-----------------------------------------------------
License Number | RN245640
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number | RN245640
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------