Basic Information
| Provider Information | |||||||||
| NPI: | 1790020733 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEALTH PARTNERS OF WESTERN OHIO | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BRYAN COMMUNITY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 329 N WEST ST | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458014332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192213072 | ||||||||
| FaxNumber: | 4195495670 | ||||||||
| Practice Location | |||||||||
| Address1: | 228 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BRYAN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435061755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197853827 | ||||||||
| FaxNumber: | 4195495670 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2012 | ||||||||
| LastUpdateDate: | 08/28/2020 | ||||||||
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| AuthorizedOfficialLastName: | SUNDERHAUS | ||||||||
| AuthorizedOfficialFirstName: | JANIS | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4192213072 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HEALTH PARTNERS OF WESTERN OHIO | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | 08/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.