Basic Information
| Provider Information | |||||||||
| NPI: | 1639133002 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JOINT TOWNSHIP DISTRICT MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | JOINT TOWNSHIP DISTRICT MEMORIAL HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 200 SAINT CLAIR AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT MARYS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458852400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193943335 | ||||||||
| FaxNumber: | 4193948485 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 SAINT CLAIR AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT MARYS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458852400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193943335 | ||||||||
| FaxNumber: | 4193948485 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2006 | ||||||||
| LastUpdateDate: | 03/23/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | POHL | ||||||||
| AuthorizedOfficialFirstName: | TRICIA | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4193943387 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336I0012X | HOS020623650 | OH | N | Suppliers | Pharmacy | Institutional Pharmacy | 282N00000X | OH | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 2131541 | 01 | PK | OTHER | 4434508 | 05 | OH | MEDICAID | 3679884 | 01 | NCPDP PROVIDER IDENTIFICATION NUMBER | OTHER | J03600323 | 01 | OH | MEDICARE ID | OTHER |