Basic Information
| Provider Information | |||||||||
| NPI: | 1710149059 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHYSICAL MEDICINE CENTER OF VAN WERT INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 140 FOX RD | ||||||||
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| City: | VAN WERT | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458912475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195865760 | ||||||||
| FaxNumber: | 4195867179 | ||||||||
| Practice Location | |||||||||
| Address1: | 123 HAMILTON ST | ||||||||
| Address2: | |||||||||
| City: | CELINA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458221909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195865760 | ||||||||
| FaxNumber: | 4195867179 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2008 | ||||||||
| LastUpdateDate: | 02/25/2009 | ||||||||
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| AuthorizedOfficialLastName: | WRAY | ||||||||
| AuthorizedOfficialFirstName: | JOCELYN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4195865760 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 35078836 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 2879354 | 05 | OH | MEDICAID |