Provider Demographics
NPI:1205852308
Name:WIRTZ, MARK ROBERT (PT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ROBERT
Last Name:WIRTZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1263 WOODLEDGE DR
Mailing Address - Street 2:
Mailing Address - City:MINERAL RIDGE
Mailing Address - State:OH
Mailing Address - Zip Code:44440
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:299 EDWARDS ST
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44502
Practice Address - Country:US
Practice Address - Phone:330-743-1168
Practice Address - Fax:330-743-1616
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH09066225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0078348Medicaid
OH364500Medicare ID - Type Unspecified