Basic Information
| Provider Information | |||||||||
| NPI: | 1467994541 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VAN WERT MEDICAL SERVICES, LTD. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | VAN WERT MEDICAL SERVICES, LTD. SPECIALTY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 140 FOX RD | ||||||||
| Address2: | STE 202 | ||||||||
| City: | VAN WERT | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458912475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192386735 | ||||||||
| FaxNumber: | 4192325271 | ||||||||
| Practice Location | |||||||||
| Address1: | 140 FOX RD | ||||||||
| Address2: | STE 209 | ||||||||
| City: | VAN WERT | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458912475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192388621 | ||||||||
| FaxNumber: | 4192380424 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2016 | ||||||||
| LastUpdateDate: | 11/07/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOLLIDAY | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | FISCAL & ADMINISTRATIVE SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 4192382390 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | VAN WERT MEDICAL SERVICES, LTD. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213EP1101X | 36002056 | OH | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Primary Podiatric Medicine | 213ES0103X | 36002056 | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 2641903 | 05 | OH | MEDICAID |