Basic Information
| Provider Information | |||||||||
| NPI: | 1053454314 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VAN WERT MEDICAL SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1250 S WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | VAN WERT | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458912551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192325279 | ||||||||
| FaxNumber: | 4192380692 | ||||||||
| Practice Location | |||||||||
| Address1: | 506 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458829228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193633008 | ||||||||
| FaxNumber: | 4193632093 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2007 | ||||||||
| LastUpdateDate: | 03/29/2018 | ||||||||
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| AuthorizedOfficialLastName: | SUTTON | ||||||||
| AuthorizedOfficialFirstName: | KELLY | ||||||||
| AuthorizedOfficialMiddleName: | KAY | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4193633008 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 398291 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 0349680 | 05 | OH | MEDICAID | 2115259 | 05 | OH | MEDICAID |