Provider Demographics
NPI:1003112863
Name:FAIRWOOD CHIROPRACTIC & PHYSICAL THERAPY
Entity Type:Organization
Organization Name:FAIRWOOD CHIROPRACTIC & PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HYTHEM
Authorized Official - Middle Name:H
Authorized Official - Last Name:RAHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:419-843-1515
Mailing Address - Street 1:5215 MONROE ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-3190
Mailing Address - Country:US
Mailing Address - Phone:419-843-1515
Mailing Address - Fax:419-715-9554
Practice Address - Street 1:5215 MONROE ST
Practice Address - Street 2:SUITE 4
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-3190
Practice Address - Country:US
Practice Address - Phone:419-843-1515
Practice Address - Fax:419-715-9554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-26
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3501111N00000X
OHPT005336225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3097474Medicaid
OH2487401Medicaid
OH4130911Medicare PIN
OH4300101Medicare PIN