Basic Information
| Provider Information | |||||||||
| NPI: | 1124369350 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VAN WERT MEDICAL SERVICES, LTD. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | VAN WERT MEDICAL SERVICES - DME | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 140 FOX RD | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | VAN WERT | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458912475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192386735 | ||||||||
| FaxNumber: | 4192325271 | ||||||||
| Practice Location | |||||||||
| Address1: | 140 FOX RD | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | VAN WERT | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458912475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192325291 | ||||||||
| FaxNumber: | 4192325292 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2013 | ||||||||
| LastUpdateDate: | 11/07/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOLLIDAY | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | VP FISCAL & ADMINISTRATIVE SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 4192382390 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | VAN WERT MEDICAL SERVICES, LTD. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 213E00000X | 36003593 | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
No ID Information.