Basic Information
| Provider Information | |||||||||
| NPI: | 1033344569 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | URGENT CARE OF WAUSEON | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 351328 | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436351328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193354600 | ||||||||
| FaxNumber: | 4193354900 | ||||||||
| Practice Location | |||||||||
| Address1: | 1190 N SHOOP AVE | ||||||||
| Address2: | |||||||||
| City: | WAUSEON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435672214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193354600 | ||||||||
| FaxNumber: | 4193354900 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2009 | ||||||||
| LastUpdateDate: | 05/02/2018 | ||||||||
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| AuthorizedOfficialLastName: | DABOUL | ||||||||
| AuthorizedOfficialFirstName: | NIZAR | ||||||||
| AuthorizedOfficialMiddleName: | Y | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4193354600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35072198 | OH | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 35074590 | OH | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207P00000X | 35079655E | OH | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2977980 | 05 | OH | MEDICAID | 759838 | 01 | OH | BCHP | OTHER |