Provider Demographics
NPI:1083896773
Name:FIRELANDS REGIONAL MEDICAL CENTER FAMILY PRACTICE CLINIC
Entity Type:Organization
Organization Name:FIRELANDS REGIONAL MEDICAL CENTER FAMILY PRACTICE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, MANAGED PRACTICES
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BEAL
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:419-557-5126
Mailing Address - Street 1:1912 HAYES AVE
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-4736
Mailing Address - Country:US
Mailing Address - Phone:419-557-7184
Mailing Address - Fax:419-557-7109
Practice Address - Street 1:1912 HAYES AVE
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-4736
Practice Address - Country:US
Practice Address - Phone:419-557-7184
Practice Address - Fax:419-557-7109
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FIRELANDS REGIONAL MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-04
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2368272Medicaid
OH2368272Medicaid