1790974558 NPI number — TAMMIE LYNN MUSSARI DPT

Table of content: TAMMIE LYNN MUSSARI DPT (NPI 1790974558)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790974558 NPI number — TAMMIE LYNN MUSSARI DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MUSSARI
Provider First Name:
TAMMIE
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

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:
1790974558
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/12/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8073 WASHINGTON VILLAGE DR
Provider Second Line Business Mailing Address:
STE 110
Provider Business Mailing Address City Name:
DAYTON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45458-1847
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-729-9448
Provider Business Mailing Address Fax Number:
330-729-9450

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
813 BOARDMAN POLAND RD
Provider Second Line Business Practice Location Address:
STE 12B
Provider Business Practice Location Address City Name:
BOARDMAN
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44512-5129
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-729-9448
Provider Business Practice Location Address Fax Number:
330-729-9450
Provider Enumeration Date:
10/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT018981 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT-018783 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P00898652 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".




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