Provider Demographics
NPI:1275033011
Name:WYANDOT MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:WYANDOT MEMORIAL HOSPITAL
Other - Org Name:WYANDOT MEDICAL PROVIDERS AT SYCAMORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:TY
Authorized Official - Middle Name:R
Authorized Official - Last Name:SHAULL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-294-4991
Mailing Address - Street 1:885 N SANDUSKY AVE
Mailing Address - Street 2:
Mailing Address - City:UPPER SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:43351-1098
Mailing Address - Country:US
Mailing Address - Phone:419-294-4991
Mailing Address - Fax:419-209-0278
Practice Address - Street 1:412 W SAFFEL AVE
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:OH
Practice Address - Zip Code:44882-9763
Practice Address - Country:US
Practice Address - Phone:419-927-6552
Practice Address - Fax:419-927-6500
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WYANDOT MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-02-19
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9687512Medicaid