Basic Information
| Provider Information | |||||||||
| NPI: | 1811174832 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADENA HEALTH SYSTEM | ||||||||
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| OtherOrganizationName: | WAVERLY FAMILY PHYSICIANS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 272 HOSPITAL RD | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | CHILLICOTHE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456019031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7407794460 | ||||||||
| FaxNumber: | 7407794257 | ||||||||
| Practice Location | |||||||||
| Address1: | 12340 STATE ROUTE 104 | ||||||||
| Address2: | |||||||||
| City: | WAVERLY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456908968 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7409415180 | ||||||||
| FaxNumber: | 7409415178 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2008 | ||||||||
| LastUpdateDate: | 06/04/2014 | ||||||||
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| AuthorizedOfficialLastName: | ROSENBERGER | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7407797582 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1475685 | 05 | OH | MEDICAID |