Provider Demographics
NPI:1003849910
Name:LODI COMMUNITY CARE CENTER
Entity Type:Organization
Organization Name:LODI COMMUNITY CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:WHELAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-948-5500
Mailing Address - Street 1:225 ELYRIA ST
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:OH
Mailing Address - Zip Code:44254-1031
Mailing Address - Country:US
Mailing Address - Phone:330-948-5533
Mailing Address - Fax:330-948-2726
Practice Address - Street 1:225 ELYRIA ST
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:OH
Practice Address - Zip Code:44254-1031
Practice Address - Country:US
Practice Address - Phone:330-948-5533
Practice Address - Fax:330-948-2726
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LODI COMMUNITY HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-07
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1801807870OtherLODI COMMUNITY HOSPITAL TYPE 2 NPI #
OH2396081Medicaid
OH3613031Medicare PIN