Provider Demographics
NPI:1053398206
Name:STATE ROAD FAMILY PRACTICE INC
Entity type:Organization
Organization Name:STATE ROAD FAMILY PRACTICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:FRANTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:440-582-1484
Mailing Address - Street 1:12744 STATE ROAD
Mailing Address - Street 2:
Mailing Address - City:NORTH ROYALTON
Mailing Address - State:OH
Mailing Address - Zip Code:44133-3910
Mailing Address - Country:US
Mailing Address - Phone:440-582-1484
Mailing Address - Fax:440-582-1594
Practice Address - Street 1:12744 STATE ROAD
Practice Address - Street 2:
Practice Address - City:NORTH ROYALTON
Practice Address - State:OH
Practice Address - Zip Code:44133-3910
Practice Address - Country:US
Practice Address - Phone:440-582-1484
Practice Address - Fax:440-582-1594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-29
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0560840001Medicare NSC