MEDICARE: MANOR AVENUE CLINIC INC

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1326022625
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MANOR AVENUE CLINIC INC

Provider Business Mailing Address
First Line	:	296 E MANOR AVE
Second Line	:
City	:	STRUTHERS
State	:	OH
Zip	:	44471-1545
Country	:	US
Telephone Number	:	330-755-3233
Fax Number	:	330-755-4511

Provider Business Practice Location Address
First Line	:	296 E MANOR AVE
Second Line	:
City	:	STRUTHERS
State	:	OH
Zip	:	44471-1545
Country	:	US
Telephone Number	:	330-755-3233
Fax Number	:	330-755-4511

Authorized Official
Title or Position	:	DO
Name	:	DR. ANDREW J LOCKSHAW III
Credential	:	DO
Telephone Number	:	330-755-3233

Provider Enumeration Date	:	12/01/2005
Last Update Date	:	08/22/2020

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