Provider Demographics
NPI:1871757260
Name:1227 EAST MARKET STREET, INC.
Entity type:Organization
Organization Name:1227 EAST MARKET STREET, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PARISA
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAVARI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-393-1501
Mailing Address - Street 1:1227 E MARKET ST
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44483-6605
Mailing Address - Country:US
Mailing Address - Phone:330-393-1501
Mailing Address - Fax:330-394-4539
Practice Address - Street 1:1227 E MARKET ST
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44483-6605
Practice Address - Country:US
Practice Address - Phone:330-393-1501
Practice Address - Fax:330-394-4539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-15
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35065329174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0504583Medicaid
OH0504583Medicaid