Basic Information
Provider Information | |||||||||
NPI: | 1437156247 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CITY OF WOOSTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WOOSTER COMMUNITY HOSPITAL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1761 BEALL AVE | ||||||||
Address2: |   | ||||||||
City: | WOOSTER | ||||||||
State: | OH | ||||||||
PostalCode: | 446912342 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3302638100 | ||||||||
FaxNumber: | 3302638525 | ||||||||
Practice Location | |||||||||
Address1: | 1761 BEALL AVE | ||||||||
Address2: |   | ||||||||
City: | WOOSTER | ||||||||
State: | OH | ||||||||
PostalCode: | 446912342 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3302638100 | ||||||||
FaxNumber: | 3302638525 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/07/2005 | ||||||||
LastUpdateDate: | 07/31/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BOYES | ||||||||
AuthorizedOfficialFirstName: | SCOTT | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF FISCAL SERVICES CFO | ||||||||
AuthorizedOfficialTelephone: | 3302638148 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X |   |   | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 000000113175 | 01 | OH | ATNEHM BLUE CROSS | OTHER | 9656251 | 05 | OH |   | MEDICAID |