Provider Demographics
NPI:1336279769
Name:PINEWOOD FAMILY PRACTICE INC
Entity Type:Organization
Organization Name:PINEWOOD FAMILY PRACTICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:P
Authorized Official - Last Name:WALSH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-353-6262
Mailing Address - Street 1:960 W WOOSTER ST
Mailing Address - Street 2:SUITE 115
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-2644
Mailing Address - Country:US
Mailing Address - Phone:419-353-6262
Mailing Address - Fax:419-353-6260
Practice Address - Street 1:960 W WOOSTER ST
Practice Address - Street 2:SUITE 115
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-2644
Practice Address - Country:US
Practice Address - Phone:419-353-6262
Practice Address - Fax:419-353-6260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35049712207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0542416Medicaid
OH9341311Medicare ID - Type Unspecified
OH0542416Medicaid