Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207PE0004X | Emergency Medical Services | 34-005587 | OH |
NPI | 1003827981 |
---|---|
Provider Name | Dr. Michael Baumgardner |
First Address | Ravenna, OH 44266-7701 |
Second Address | Ravenna, OH 44266-3929 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/08/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000000244880 | ANTHEM PROVIDER NUMBER (01) | OH |