MEDICARE: PRIMARY HEALTHCARE OF ASHTABULA

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	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1710042734
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIMARY HEALTHCARE OF ASHTABULA

Provider Business Mailing Address
First Line	:	5266 STATE ROUTE 45
Second Line	:
City	:	ROME
State	:	OH
Zip	:	44085-9404
Country	:	US
Telephone Number	:	440-563-5028
Fax Number	:

Provider Business Practice Location Address
First Line	:	5266 STATE ROUTE 45
Second Line	:
City	:	ROME
State	:	OH
Zip	:	44085-9404
Country	:	US
Telephone Number	:	440-563-5028
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	BRUCE PETERS
Credential	:
Telephone Number	:	440-563-5028

Provider Enumeration Date	:	12/27/2006
Last Update Date	:	08/22/2020

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