Basic Information
| Provider Information | |||||||||
| NPI: | 1861908071 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WYANDOT MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WYANDOT MEDICAL PROVIDERS AT FOREST | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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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: | 112 E LIMA ST | ||||||||
| Address2: | |||||||||
| City: | FOREST | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458431116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192735104 | ||||||||
| FaxNumber: | 4192735106 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2017 | ||||||||
| LastUpdateDate: | 09/23/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 08/11/2022 | ||||||||
| NPIReactivationDate: | 09/23/2022 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SHAULL | ||||||||
| AuthorizedOfficialFirstName: | TY | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 4192944991 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WYANDOT MEMORIAL HOSPITAL | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 0394927 | 05 | OH | MEDICAID |