1285815076 NPI number — WAUSEON FAMILY PRACTICE

Table of content: HOLLY MARIE PORTER LADC (NPI 1780150722)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285815076 NPI number — WAUSEON FAMILY PRACTICE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WAUSEON FAMILY PRACTICE
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:
1285815076
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
725 S SHOOP AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAUSEON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43567-1702
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-337-9990
Provider Business Mailing Address Fax Number:
419-337-9996

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
725 S SHOOP AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAUSEON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43567-1702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-337-9990
Provider Business Practice Location Address Fax Number:
419-337-9996
Provider Enumeration Date:
11/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ISSA
Authorized Official First Name:
RAMON
Authorized Official Middle Name:
ANTHONY
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
419-337-9990

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  35083971 , 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: 2504669 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000350389 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".




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