Basic Information
| Provider Information | |||||||||
| NPI: | 1952774689 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WYANDOT MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WYANDOT MEMORIAL HOSPITAL - URGENT CARE SERVICES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 885 N SANDUSKY AVENUE | ||||||||
| Address2: | |||||||||
| City: | UPPER SANDUSKY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433511098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192944991 | ||||||||
| FaxNumber: | 4192942233 | ||||||||
| Practice Location | |||||||||
| Address1: | 885 N SANDUSKY AVENUE | ||||||||
| Address2: | |||||||||
| City: | UPPER SANDUSKY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433511098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192944991 | ||||||||
| FaxNumber: | 4192942233 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2015 | ||||||||
| LastUpdateDate: | 11/03/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | D'ETTORRE | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4192944991 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WYANDOT MEMORIAL HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | 1296 | OH | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | 9687512 | 05 | OH | MEDICAID |