Basic Information
Provider Information | |||||||||
NPI: | 1578586095 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WOJCIECHOWSKI | ||||||||
FirstName: | EDWARD | ||||||||
MiddleName: | JOSEPH | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 745 HASKINS RD | ||||||||
Address2: | SUITE B | ||||||||
City: | BOWLING GREEN | ||||||||
State: | OH | ||||||||
PostalCode: | 434021637 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4193537069 | ||||||||
FaxNumber: | 4193537076 | ||||||||
Practice Location | |||||||||
Address1: | 1039 HASKINS RD | ||||||||
Address2: | SUITE A | ||||||||
City: | BOWLING GREEN | ||||||||
State: | OH | ||||||||
PostalCode: | 434029065 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4193521121 | ||||||||
FaxNumber: | 4193521179 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/25/2006 | ||||||||
LastUpdateDate: | 02/13/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35.073273 | OH | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 2132794 | 05 | OH |   | MEDICAID |