1710149059 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 1710149059 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:
1710149059
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/25/2009
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:
Provider Business Mailing Address City Name:
VAN WERT
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45891-2475
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-586-5760
Provider Business Mailing Address Fax Number:
419-586-7179

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
123 HAMILTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CELINA
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45822-1909
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-586-5760
Provider Business Practice Location Address Fax Number:
419-586-7179
Provider Enumeration Date:
06/27/2008

Additional Information

Authorized Official

Authorized Official Last Name:
WRAY
Authorized Official First Name:
JOCELYN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PHYSICIAN/OWNER
Authorized Official Telephone Number:
419-586-5760

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , with the licence number:  35078836 , 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".




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