Provider Demographics
NPI:1730194598
Name:FAMILY MEDICINE OF STARK COUNTY, INC.
Entity type:Organization
Organization Name:FAMILY MEDICINE OF STARK COUNTY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GUST
Authorized Official - Middle Name:
Authorized Official - Last Name:PANTELAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-499-5600
Mailing Address - Street 1:6512 WHIPPLE AVE NW
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-7340
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6512 WHIPPLE AVE NW
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-7340
Practice Address - Country:US
Practice Address - Phone:330-499-5600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH056025207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHO790818Medicare UPIN
OHD97987Medicare UPIN
OHF74094Medicare UPIN
OHH16981Medicare UPIN
OHE50092Medicare UPIN