Basic Information
| Provider Information | |||||||||
| NPI: | 1619509429 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCGOUGH | ||||||||
| FirstName: | HAILEY | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 530 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458041500 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1941 CARLIN ST | ||||||||
| Address2: | |||||||||
| City: | FINDLAY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458401460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194228616 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2020 | ||||||||
| LastUpdateDate: | 02/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | OH | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 4199065690 | 05 | OH | MEDICAID |