Taxonomy Codes
The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:
| No. |
Taxonomy Code |
Taxonomy Clasification |
Taxonomy Specialization |
License Number |
License State |
Primary |
| 1 | 261Q00000X | Clinic/Center | | 34-006816-R | OHIO | No |
| 2 | 261QH0100X | Clinic/Center | Health Service | 34-006816-R | OHIO | No |
| 3 | 261QM0850X | Clinic/Center | Adult Mental Health | 34-006816-R | OHIO | No |
| 4 | 261QM2500X | Clinic/Center | Medical Specialty | 34-006816-R | OHIO | No |
| 5 | 261QP2300X | Clinic/Center | Primary Care | 34-006816-R | OHIO | No |
| 6 | 261QR0405X | Clinic/Center | Rehabilitation, Substance Use Disorder | 34-006816-R | OHIO | No |
| 7 | 261QM1300X | Clinic/Center | Multi-Specialty | 34-006816-R | OHIO | Yes |
Other Identifiers
The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.
| No. |
Other Provider Identifier |
Other Provider Identifier Type |
Other Provider Identifier State |
Other Provider Identifier Issuer |
| 1 | 000012833-00 | OTHER | OHIO | OHIO BUREAU OF WORKERS' COMPENSATION CERTIFIED |
| 2 | 34-006816-R | OTHER | OHIO | STATE OF OHIO MEDICAL LICENSE # 34-006816-R |
| 3 | 2174418 | MEDICAID | OHIO | |
| 4 | 36D2026176 | OTHER | OHIO | CLIA WAIVER CERTIFICATE # 36D2026176 ACUTE OPIOID DETOX CLINIC, U.S.A. |
| 5 | 8873 | OTHER | ILLINOIS | AMERICAN OSTEOPATHIC BOARD OF FAMILY PHYSICIANS BOARD CERTIFICATION |
| 6 | RE 4018311 | OTHER | OHIO | MEDICARE |
| 7 | 064509 | OTHER | OHIO | AOA # AMERICAN OSTEOPATHIC ASSOCIATION ID# 064509 |
| 8 | H051310 | OTHER | OHIO | MEDICARE ID AS OF 7-17-2013 |
