MEDICARE: CENTER STREET COMMUNITY 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	261QF0400X	Federally Qualified Health Center (FQHC)		OH

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	:	1346417417
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTER STREET COMMUNITY CLINIC INC

Provider Business Mailing Address
First Line	:	205 W CENTER ST
Second Line	:	SUITE 200
City	:	MARION
State	:	OH
Zip	:	43302-3700
Country	:	US
Telephone Number	:	740-751-4189
Fax Number	:	740-751-4866

Provider Business Practice Location Address
First Line	:	205 W CENTER ST
Second Line	:	SUITE 200
City	:	MARION
State	:	OH
Zip	:	43302-3700
Country	:	US
Telephone Number	:	740-751-4189
Fax Number	:	740-751-4866

Authorized Official
Title or Position	:	CEO/EXECUTIVE DIRECTOR
Name	:	CLIFF G EDWARDS
Credential	:
Telephone Number	:	740-751-6380

Provider Enumeration Date	:	05/08/2008
Last Update Date	:	01/21/2015

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