1700021086 NPI number — MRS. MEGAN MARIE BRODWOLF MPT

Table of content: MRS. MEGAN MARIE BRODWOLF MPT (NPI 1700021086)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700021086 NPI number — MRS. MEGAN MARIE BRODWOLF MPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRODWOLF
Provider First Name:
MEGAN
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SCHROEDER
Provider Other First Name:
MEGAN
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
MPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1700021086
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/04/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1880 N. PERRY ST
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
OTTAWA
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45875-1164
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-523-9003
Provider Business Mailing Address Fax Number:
419-523-9143

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
333 NORTH STREET
Provider Second Line Business Practice Location Address:
STE 102
Provider Business Practice Location Address City Name:
DELPHOS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45833-1070
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-692-0095
Provider Business Practice Location Address Fax Number:
419-692-0097
Provider Enumeration Date:
12/15/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2251X0800X , with the licence number:  PT.012139 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2251343 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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