Provider Demographics
NPI:1003875949
Name:MARY RUTAN HOSPITAL
Entity Type:Organization
Organization Name:MARY RUTAN HOSPITAL
Other - Org Name:MAD RIVER FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP/FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:RON
Authorized Official - Middle Name:
Authorized Official - Last Name:CARMIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-592-4015
Mailing Address - Street 1:4879 US HIGHWAY 68 S
Mailing Address - Street 2:
Mailing Address - City:WEST LIBERTY
Mailing Address - State:OH
Mailing Address - Zip Code:43357-9525
Mailing Address - Country:US
Mailing Address - Phone:937-599-1411
Mailing Address - Fax:937-465-9945
Practice Address - Street 1:4879 US HIGHWAY 68 S
Practice Address - Street 2:
Practice Address - City:WEST LIBERTY
Practice Address - State:OH
Practice Address - Zip Code:43357-9525
Practice Address - Country:US
Practice Address - Phone:937-599-1411
Practice Address - Fax:937-465-9945
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARY RUTAN HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-03-20
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2055332Medicaid
OHMA9296981Medicare ID - Type Unspecified