Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081S0010X | Sports Medicine | AT004792 | OH |
Y | 213ES0000X | Sports Medicine | AT004792 | OH |
NPI | 1477170603 |
---|---|
Provider Name | Benjamin Tate JR. |
First Address | Heath, OH 43056-1394 |
Second Address | Granville, OH 43023-1100 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/07/2020 |
Last Update Date | 04/07/2020 |