MEDICARE: STATE OF OHIO DEPARTMENT OF MENTAL HEALTH

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	251B00000X	Case Management Agency		OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	10386	OTHER	OH	MACSIS

General Provider Information

NPI Number	:	1184693269
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATE OF OHIO DEPARTMENT OF MENTAL HEALTH

Provider Business Mailing Address
First Line	:	30 E. BROAD ST
Second Line	:	11TH FLOOR - FISCAL ADMINISTRATION
City	:	COLUMBUS
State	:	OH
Zip	:	43215-3430
Country	:	US
Telephone Number	:	614-466-6583
Fax Number	:	614-644-5331

Provider Business Practice Location Address
First Line	:	2321 SECOND ST
Second Line	:	SUITE 102
City	:	CUYAHOGA FALLS
State	:	OH
Zip	:	44221-2520
Country	:	US
Telephone Number	:	330-833-3135
Fax Number	:	330-833-9216

Authorized Official
Title or Position	:	FISCAL MANAGER
Name	:	MS. TONYA MARIE FASONE
Credential	:
Telephone Number	:	614-466-9930

Provider Enumeration Date	:	03/14/2006
Last Update Date	:	01/29/2008

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Directions to “STATE OF OHIO DEPARTMENT OF MENTAL HEALTH ” Practice Location

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