Basic Information
| Provider Information | |||||||||
| NPI: | 1053827303 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WYANDOT MEMORIAL HOSPITAL | ||||||||
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| OtherOrganizationName: | WYANDOT MEMORIAL HOSPITAL PHYSICIAN SERVICES B | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 885 N SANDUSKY AVENUE | ||||||||
| Address2: | |||||||||
| City: | UPPER SANDUSKY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433511098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192944991 | ||||||||
| FaxNumber: | 4192090278 | ||||||||
| Practice Location | |||||||||
| Address1: | 103 N PENNINGTON ST | ||||||||
| Address2: | |||||||||
| City: | SYCAMORE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448829408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199276552 | ||||||||
| FaxNumber: | 4199276500 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2017 | ||||||||
| LastUpdateDate: | 06/16/2018 | ||||||||
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| AuthorizedOfficialLastName: | SCHWENNING | ||||||||
| AuthorizedOfficialFirstName: | MARY ANNE | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL STAFF COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 4192944991 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WYANDOT MEMORIAL HOSPITAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 9687512 | 05 | OH | MEDICAID |