Basic Information
| Provider Information | |||||||||
| NPI: | 1326112095 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARION COUNTY AUDITOR | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MARION PUBLIC HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 181 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433023964 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403876520 | ||||||||
| FaxNumber: | 7403832546 | ||||||||
| Practice Location | |||||||||
| Address1: | 181 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433023964 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403876520 | ||||||||
| FaxNumber: | 7403832546 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2006 | ||||||||
| LastUpdateDate: | 06/03/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JANCHAR | ||||||||
| AuthorizedOfficialFirstName: | LEONARD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7403876520 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MARION COUNTY AUDITOR | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251K00000X | Y | Agencies | Public Health or Welfare |
ID Information
| ID | Type | State | Issuer | Description | 0568916 | 05 | OH | MEDICAID | 06334 | 05 | OH | MEDICAID | 0835761 | 05 | OH | MEDICAID |