1063494250 NPI number — PHYSICAL MEDICINE CENTER OF VAN WERT, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063494250 NPI number — PHYSICAL MEDICINE CENTER OF VAN WERT, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSICAL MEDICINE CENTER OF VAN WERT, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063494250
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/13/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
140 FOX RD
Provider Second Line Business Mailing Address:
SUITE 303
Provider Business Mailing Address City Name:
VAN WERT
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45891-2496
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-232-6333
Provider Business Mailing Address Fax Number:
419-232-6444

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
140 FOX RD
Provider Second Line Business Practice Location Address:
SUITE 303
Provider Business Practice Location Address City Name:
VAN WERT
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45891-2496
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-232-6333
Provider Business Practice Location Address Fax Number:
419-232-6444
Provider Enumeration Date:
11/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
WRAY
Authorized Official First Name:
JOCELYN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
419-232-6333

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , with the licence number:  35-078836 , 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: 2879354 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: DO8314 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




Copyright © 2007-2026 www.npivalidator.com