MEDICARE: PHYSICIAN MANAGEMENT SERVICES OF OHIO LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PHC059	OTHER		MEDICARE PTAN

General Provider Information

NPI Number	:	1144533407
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHYSICIAN MANAGEMENT SERVICES OF OHIO LLC

Provider Business Mailing Address
First Line	:	400 GATLIN AVE
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32806-6940
Country	:	US
Telephone Number	:	888-829-8550
Fax Number	:	888-843-7191

Provider Business Practice Location Address
First Line	:	211 15TH ST NW
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44703-1704
Country	:	US
Telephone Number	:	888-829-8550
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CASEY DELOACH
Credential	:
Telephone Number	:	888-829-8550

Provider Enumeration Date	:	07/15/2010
Last Update Date	:	10/21/2024

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