Provider Demographics
NPI:1902080310
Name:SANDUSKY MEDICAL & PAIN CLINIC
Entity Type:Organization
Organization Name:SANDUSKY MEDICAL & PAIN CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ISSAM
Authorized Official - Middle Name:AHMAD
Authorized Official - Last Name:AL-TURK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-621-1555
Mailing Address - Street 1:208 E PERKINS AVE
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-4905
Mailing Address - Country:US
Mailing Address - Phone:419-621-1555
Mailing Address - Fax:419-621-1405
Practice Address - Street 1:208 E PERKINS AVE
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-4905
Practice Address - Country:US
Practice Address - Phone:419-621-1555
Practice Address - Fax:419-621-1405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-20
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35074103207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2053334Medicaid
OH2053334Medicaid
OHG66671Medicare UPIN