Basic Information
| Provider Information | |||||||||
| NPI: | 1477554475 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WYANDOT MEMORIAL HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 885 N SANDUSKY AVE | ||||||||
| Address2: | |||||||||
| City: | UPPER SANDUSKY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433511031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192944991 | ||||||||
| FaxNumber: | 4192942233 | ||||||||
| Practice Location | |||||||||
| Address1: | 885 N SANDUSKY AVE | ||||||||
| Address2: | |||||||||
| City: | UPPER SANDUSKY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433511031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192944991 | ||||||||
| FaxNumber: | 4190920278 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2005 | ||||||||
| LastUpdateDate: | 03/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | SHAULL | ||||||||
| AuthorizedOfficialFirstName: | TY | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 4192944991 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 03/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 000000198227 | 01 | ANTHEM BC/BS | OTHER | 9687512 | 05 | OH | MEDICAID |