Basic Information
Provider Information | |||||||||
NPI: | 1255401345 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | H.B. MAGRUDER HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MAGRUDER HOSPITAL PC EMERGENCY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 615 FULTON ST | ||||||||
Address2: |   | ||||||||
City: | PORT CLINTON | ||||||||
State: | OH | ||||||||
PostalCode: | 434522001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4197343131 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 615 FULTON ST | ||||||||
Address2: |   | ||||||||
City: | PORT CLINTON | ||||||||
State: | OH | ||||||||
PostalCode: | 434522001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4197343131 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/08/2006 | ||||||||
LastUpdateDate: | 08/19/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MARSICO | ||||||||
AuthorizedOfficialFirstName: | NICK | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT - CEO | ||||||||
AuthorizedOfficialTelephone: | 4197343131 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/19/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 146M00000X | 1252 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Emergency Medical Service Providers | Emergency Medical Technician, Intermediate |   |
ID Information
ID | Type | State | Issuer | Description | 395857 | 01 | OH | BLACK LUNG ER | OTHER | 5430662 | 05 | OH |   | MEDICAID | 6460950 | 01 | OH | AETNA ER | OTHER | 709136 | 01 | OH | BUCKEYE ER | OTHER | 03718 | 01 | OH | PARAMOUNT ER | OTHER | H3613141 | 01 | OH | HUMANA MEDICARE ER | OTHER |