Provider Demographics
NPI:1275059982
Name:ISLAND MEDICAL VAN WERT LLC
Entity Type:Organization
Organization Name:ISLAND MEDICAL VAN WERT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF LEGAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHARLEY
Authorized Official - Suffix:
Authorized Official - Credentials:ESQ
Authorized Official - Phone:240-686-2300
Mailing Address - Street 1:12420 MILESTONE CENTER DR STE 200
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20876-7111
Mailing Address - Country:US
Mailing Address - Phone:240-686-2300
Mailing Address - Fax:
Practice Address - Street 1:1250 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:VAN WERT
Practice Address - State:OH
Practice Address - Zip Code:45891-2599
Practice Address - Country:US
Practice Address - Phone:127-505-9982
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-15
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty