Basic Information
| Provider Information | |||||||||
| NPI: | 1083688097 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STATE OF OHIO OFFICE OF BUDGET AND MANAGEMENT STATE ACCOUNTING | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NORTHWEST OHIO PYSCHIATRIC HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 E BROAD ST | ||||||||
| Address2: | 11TH FL, ATTN:BETTY TAYLOR | ||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432153414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147282546 | ||||||||
| FaxNumber: | 6146449116 | ||||||||
| Practice Location | |||||||||
| Address1: | 930 S DETROIT AVE | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436142701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193811881 | ||||||||
| FaxNumber: | 4193891361 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2006 | ||||||||
| LastUpdateDate: | 02/17/2015 | ||||||||
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| AuthorizedOfficialLastName: | COLLETTI | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DEPUTY DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6144524343 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283Q00000X | NA | Y | Hospitals | Psychiatric Hospital |
ID Information
| ID | Type | State | Issuer | Description | 0150321 | 05 | OH | MEDICAID |