Basic Information
| Provider Information | |||||||||
| NPI: | 1720594971 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WYANDOT MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WYANDOT MEDICAL PROVIDERS AT TARHE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 885 N SANDUSKY AVE | ||||||||
| Address2: | |||||||||
| City: | UPPER SANDUSKY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433511098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192944991 | ||||||||
| FaxNumber: | 4192090278 | ||||||||
| Practice Location | |||||||||
| Address1: | 245 TARHE TRL | ||||||||
| Address2: | |||||||||
| City: | UPPER SANDUSKY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433518700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192941525 | ||||||||
| FaxNumber: | 4192090252 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2017 | ||||||||
| LastUpdateDate: | 08/11/2022 | ||||||||
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| AuthorizedOfficialLastName: | SHAULL | ||||||||
| AuthorizedOfficialFirstName: | TY | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 4192944991 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 08/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 0394798 | 05 | OH | MEDICAID |