Provider Demographics
NPI:1053565986
Name:FAMILY STATCARE OF NORTHEAST OHIO, LLC
Entity type:Organization
Organization Name:FAMILY STATCARE OF NORTHEAST OHIO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEN
Authorized Official - Middle Name:
Authorized Official - Last Name:FILBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-416-6153
Mailing Address - Street 1:230 QUADRAL DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:WADSWORTH
Mailing Address - State:OH
Mailing Address - Zip Code:44281-8376
Mailing Address - Country:US
Mailing Address - Phone:330-336-3280
Mailing Address - Fax:330-336-5325
Practice Address - Street 1:175 GREAT OAKS TRL
Practice Address - Street 2:
Practice Address - City:WADSWORTH
Practice Address - State:OH
Practice Address - Zip Code:44281-8712
Practice Address - Country:US
Practice Address - Phone:330-336-3588
Practice Address - Fax:330-336-1328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-05
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2939511Medicaid
OH9380751Medicare PIN