1104936624 NPI number — BES OF OHIO, LLC, DBA MEDGROUP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104936624 NPI number — BES OF OHIO, LLC, DBA MEDGROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BES OF OHIO, LLC, DBA MEDGROUP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104936624
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/29/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 567
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHAGRIN FALLS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44022-0567
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-464-5160
Provider Business Mailing Address Fax Number:
216-464-5983

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3913 DARROW RD
Provider Second Line Business Practice Location Address:
SUITE #100
Provider Business Practice Location Address City Name:
STOW
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44224-2621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-688-7900
Provider Business Practice Location Address Fax Number:
330-688-1866
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ERICKSON
Authorized Official First Name:
DEAN
Authorized Official Middle Name:
W.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
330-864-1916

Provider Taxonomy Codes

  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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