Organization
BEREA FAMILY MEDICINE, INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MARY ELLEN WIGGENHORN LPN (PRACTICE MANAGER)
(440) 234-0502
Entity
Organization
Contact information
Practice address
853 W BAGLEY RD, BEREA, OH 44017-2903
(440) 234-0502
(440) 234-0590
Mailing address
853 W BAGLEY RD, BEREA, OH 44017-2903
(440) 234-0502
(440) 234-0590
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
35049545
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
2849172
—
OH
Enumeration date
04/06/2007
Last updated
10/20/2010
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