Basic Information
| Provider Information | |||||||||
| NPI: | 1790131050 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AVITA ONTARIO HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 269 PORTLAND WAY S | ||||||||
| Address2: | |||||||||
| City: | GALION | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448332312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194684841 | ||||||||
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| Practice Location | |||||||||
| Address1: | 715 RICHLAND MALL | ||||||||
| Address2: | |||||||||
| City: | ONTARIO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449063802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5673077666 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2016 | ||||||||
| LastUpdateDate: | 05/05/2016 | ||||||||
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| AuthorizedOfficialLastName: | DRAIME | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | ERIC | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4194680501 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AVITA HEALTH SYSTEM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
No ID Information.