Provider Demographics
NPI:1306024534
Name:MOBILE PHYSICIANS OF OHIO INC
Entity type:Organization
Organization Name:MOBILE PHYSICIANS OF OHIO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:419-882-5000
Mailing Address - Street 1:5151 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-2184
Mailing Address - Country:US
Mailing Address - Phone:419-882-5000
Mailing Address - Fax:
Practice Address - Street 1:5151 MAIN ST
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-2184
Practice Address - Country:US
Practice Address - Phone:419-882-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-11
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9364351Medicare PIN