Basic Information
| Provider Information | |||||||||
| NPI: | 1447201470 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WAKEMAN AREA FAMILY CARE CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24 HYDE ST | ||||||||
| Address2: | |||||||||
| City: | WAKEMAN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448899301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408392226 | ||||||||
| FaxNumber: | 4408391339 | ||||||||
| Practice Location | |||||||||
| Address1: | 24 HYDE ST | ||||||||
| Address2: | |||||||||
| City: | WAKEMAN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448899301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408392226 | ||||||||
| FaxNumber: | 4408391339 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2006 | ||||||||
| LastUpdateDate: | 12/19/2007 | ||||||||
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| AuthorizedOfficialLastName: | TANIGAWA | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4408392226 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 50000956 | OH | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363LF0000X | NP08465 | OH | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207Q00000X | 35062083 | OH | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2158481 | 05 | OH | MEDICAID |