Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207PE0004X | Emergency Medical Services | 35056121S | OH |
NPI | 1033103734 |
---|---|
Provider Name | John Smith |
First Address | Sandusky, OH 44870-7024 |
Second Address | Sandusky, OH 44870-3335 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/09/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0883343 | (05) | OH |
F04244 | (02) |