Provider Demographics
NPI:1518159144
Name:OAKMONT FAMILY MEDICINE LLC
Entity type:Organization
Organization Name:OAKMONT FAMILY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAY
Authorized Official - Middle Name:J
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:419-874-8745
Mailing Address - Street 1:1103 VILLAGE SQUARE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-1783
Mailing Address - Country:US
Mailing Address - Phone:419-874-8745
Mailing Address - Fax:419-874-8748
Practice Address - Street 1:1103 VILLAGE SQUARE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-1783
Practice Address - Country:US
Practice Address - Phone:419-874-8745
Practice Address - Fax:419-874-8748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-17
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3895207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHOA9371161Medicare PIN