1427189604 NPI number — CORPORATION OF VILLAGE OF PORT WILLIAM

Table of content: (NPI 1427189604)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427189604 NPI number — CORPORATION OF VILLAGE OF PORT WILLIAM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CORPORATION OF VILLAGE OF PORT WILLIAM
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:
6
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:
1427189604
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/10/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 263
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILMINGTON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45177-0263
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-424-3701
Provider Business Mailing Address Fax Number:
937-291-2971

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
220 SECOND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT WILLIAM
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45164
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-302-7010
Provider Business Practice Location Address Fax Number:
937-486-5300
Provider Enumeration Date:
03/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
IANSON
Authorized Official First Name:
KEN
Authorized Official Middle Name:
Authorized Official Title or Position:
MAYOR
Authorized Official Telephone Number:
937-302-7010

Provider Taxonomy Codes

  • Taxonomy code: 341600000X , with the licence number:  02-0327100 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3416L0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 000000525508 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2782118 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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