1821040007 NPI number — SHELDEN C WICAL D.O.

Table of content: SHELDEN C WICAL D.O. (NPI 1821040007)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821040007 NPI number — SHELDEN C WICAL D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WICAL
Provider First Name:
SHELDEN
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1821040007
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/24/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 SAINT CLAIR AVE
Provider Second Line Business Mailing Address:
GRAND LAKE PHYSICIAN PRACTICES
Provider Business Mailing Address City Name:
SAINT MARYS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45885-2400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-394-3387
Provider Business Mailing Address Fax Number:
419-628-9501

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4463 STATE ROUTE 66
Provider Second Line Business Practice Location Address:
MIAMI ERIE FAMILY PRACTICE & PEDIATRICE
Provider Business Practice Location Address City Name:
MINSTER
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45865-8727
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-628-3821
Provider Business Practice Location Address Fax Number:
419-628-9501
Provider Enumeration Date:
05/16/2006

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:  34007266 , 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: 2236940 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9934723 . This is a "MEDICARE GROUP PTAN" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 1104024546 . This is a "NPI GROUP - MIAMI & ERIE FAMILY PRACTICE & PEDIATRICS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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