1508836016 NPI number — DR. DAVID MATTHEW WENDT MD

Table of content: DR. DAVID MATTHEW WENDT MD (NPI 1508836016)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508836016 NPI number — DR. DAVID MATTHEW WENDT MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WENDT
Provider First Name:
DAVID
Provider Middle Name:
MATTHEW
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1508836016
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/26/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19234 DETROIT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKY RIVER
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44116-1706
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-356-3640
Provider Business Mailing Address Fax Number:
440-356-3729

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19234 DETROIT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCKY RIVER
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44116-1706
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-356-3640
Provider Business Practice Location Address Fax Number:
440-356-3729
Provider Enumeration Date:
01/25/2006

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: 207Q00000X , with the licence number:  35080324 , 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: 000000232253 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 080189174 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00706005 . This is a "RRCARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2338983 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: C80324 . This is a "SUMMA" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 000000540966 . This is a "ANTHEM /ROCKY RIVER" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: P00613207 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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