Provider Demographics
NPI:1538353883
Name:TRUMBULL MAHONING MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:TRUMBULL MAHONING MEDICAL GROUP, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER/EXECUTIVE
Authorized Official - Prefix:DR
Authorized Official - First Name:MOURAD
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSTOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-372-8800
Mailing Address - Street 1:20 OHLTOWN RD
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44515-2331
Mailing Address - Country:US
Mailing Address - Phone:330-797-9705
Mailing Address - Fax:330-270-5997
Practice Address - Street 1:20 OHLTOWN RD
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44515-2331
Practice Address - Country:US
Practice Address - Phone:330-797-9705
Practice Address - Fax:330-270-5997
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRUMBULL MAHONING MEDICAL GROUP, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-30
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1426141OtherHIGHMARK BC/BS PA
OH000000243183OtherANTHEM BC/BS OHIO
OH0468677Medicaid
OH000000243183OtherANTHEM BC/BS OHIO
OH1426141OtherHIGHMARK BC/BS PA
OH=========003OtherTRICARE
OH=========025OtherMEDICAL MUTUAL OF OHIO
OH1426141OtherHIGHMARK BC/BS PA