Provider Demographics
NPI:1053454314
Name:VAN WERT MEDICAL SERVICES
Entity Type:Organization
Organization Name:VAN WERT MEDICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:SUTTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-363-3008
Mailing Address - Street 1:1250 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:VAN WERT
Mailing Address - State:OH
Mailing Address - Zip Code:45891-2551
Mailing Address - Country:US
Mailing Address - Phone:419-232-5279
Mailing Address - Fax:419-238-0692
Practice Address - Street 1:506 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:OH
Practice Address - Zip Code:45882-9228
Practice Address - Country:US
Practice Address - Phone:419-363-3008
Practice Address - Fax:419-363-2093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH398291174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0349680Medicaid
OH2115259Medicaid
OH2115259Medicaid
OH0349680Medicaid
OHCO1511Medicare UPIN
OHSE0445682Medicare ID - Type UnspecifiedMEDICARE