Provider Demographics
NPI:1114144300
Name:DRS. DETRICK & DETRICK INC.
Entity Type:Organization
Organization Name:DRS. DETRICK & DETRICK INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CYNDEE
Authorized Official - Middle Name:J
Authorized Official - Last Name:DETRICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-893-3316
Mailing Address - Street 1:5757 MONCLOVA ROAD
Mailing Address - Street 2:SUITE 14
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537
Mailing Address - Country:US
Mailing Address - Phone:419-893-3316
Mailing Address - Fax:
Practice Address - Street 1:5757 MONCLOVA ROAD
Practice Address - Street 2:SUITE 14
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537
Practice Address - Country:US
Practice Address - Phone:419-893-3316
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN113039163WR0006X
OH032039822363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCB3101OtherMEDICARE RAILROAD