Basic Information
| Provider Information | |||||||||
| NPI: | 1972749570 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. LUKE'S HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SLH/UT FAMILY MEDICINE RESIDENCY PROGRAM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 WASHINGTON AVE. | ||||||||
| Address2: | COMPREHENSIVE MEDICAL MANAGEMENT | ||||||||
| City: | NEWPORT | ||||||||
| State: | KY | ||||||||
| PostalCode: | 41018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8596558554 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6005 MONCLOVA RD | ||||||||
| Address2: | SLH/UT FAMILY MEDICINE RESIDENCY PROGRAM | ||||||||
| City: | MAUMEE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198918024 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2009 | ||||||||
| LastUpdateDate: | 01/05/2009 | ||||||||
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| AuthorizedOfficialLastName: | WAGNER | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | REVENUE CYCLE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4198918024 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST. LUKE'S HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 7648602 | 05 | OH | MEDICAID |