Basic Information
| Provider Information | |||||||||
| NPI: | 1538174388 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RICHLAND SURGICAL ASSOCIATES INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 215 WOOD ST | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449032260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195222833 | ||||||||
| FaxNumber: | 4195241619 | ||||||||
| Practice Location | |||||||||
| Address1: | 215 WOOD ST | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449032260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195222833 | ||||||||
| FaxNumber: | 4195241619 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2006 | ||||||||
| LastUpdateDate: | 04/10/2014 | ||||||||
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| AuthorizedOfficialLastName: | DETRICH | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4195222833 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 0148496 | 05 | OH | MEDICAID |