Basic Information
| Provider Information | |||||||||
| NPI: | 1932535820 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHWEST OHIO RHEUMATOLOGY INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 78000 | ||||||||
| Address2: | DEPT 78190 | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482781907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8005144390 | ||||||||
| FaxNumber: | 4408083675 | ||||||||
| Practice Location | |||||||||
| Address1: | 132 GARAU ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | BLUFFTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458171086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193580132 | ||||||||
| FaxNumber: | 4193580319 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2013 | ||||||||
| LastUpdateDate: | 10/28/2014 | ||||||||
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| AuthorizedOfficialLastName: | GIDEON | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4193692190 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RR0500X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
ID Information
| ID | Type | State | Issuer | Description | DU2173 | 01 | OH | RAILROAD MEDICARE | OTHER | 0091899 | 05 | OH | MEDICAID |