Provider Demographics
NPI:1083713770
Name:DEFIANCE REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:DEFIANCE REGIONAL MEDICAL CENTER
Other - Org Name:DEFIANCE REGIONAL PSYCHIATRIC SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:M
Authorized Official - Last Name:PEFFLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-783-6805
Mailing Address - Street 1:1250 RALSTON AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:DEFIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:43512-5311
Mailing Address - Country:US
Mailing Address - Phone:419-783-6805
Mailing Address - Fax:419-783-6804
Practice Address - Street 1:1250 RALSTON AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512-5311
Practice Address - Country:US
Practice Address - Phone:419-783-6805
Practice Address - Fax:419-783-6804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI00044271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHS66075Medicare UPIN
OHSHSW75801Medicare ID - Type Unspecified