MEDICARE: JTDM FAMILY PRACTICE 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	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1750937090
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JTDM FAMILY PRACTICE LLC

Provider Business Mailing Address
First Line	:	200 SAINT CLAIR AVE
Second Line	:
City	:	SAINT MARYS
State	:	OH
Zip	:	45885-2400
Country	:	US
Telephone Number	:	419-394-3335
Fax Number	:	419-394-8485

Provider Business Practice Location Address
First Line	:	1013 E SPRING ST
Second Line	:
City	:	SAINT MARYS
State	:	OH
Zip	:	45885-2447
Country	:	US
Telephone Number	:	419-394-8664
Fax Number	:	419-394-1148

Authorized Official
Title or Position	:	CFO
Name	:	TRICIA A POHL
Credential	:
Telephone Number	:	419-394-3335

Provider Enumeration Date	:	08/13/2019
Last Update Date	:	02/06/2024

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