Basic Information
Provider Information | |||||||||
NPI: | 1033135009 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WOOSTER CLINIC, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1740 CLEVELAND RD | ||||||||
Address2: |   | ||||||||
City: | WOOSTER | ||||||||
State: | OH | ||||||||
PostalCode: | 446912204 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3302874500 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1740 CLEVELAND RD | ||||||||
Address2: |   | ||||||||
City: | WOOSTER | ||||||||
State: | OH | ||||||||
PostalCode: | 446912204 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3302874500 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/14/2006 | ||||||||
LastUpdateDate: | 03/30/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LONGVILLE | ||||||||
AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
AuthorizedOfficialMiddleName: | L. | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF ACCT. OFFICER AND CONTROLLER | ||||||||
AuthorizedOfficialTelephone: | 2166367416 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/30/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
ID | Type | State | Issuer | Description | 000000168661 | 01 | OH | ANTHEM | OTHER | 2070593 | 05 | OH |   | MEDICAID |