Provider Demographics
NPI:1376643411
Name:WESTERN OHIO PODIATRIC MEDICAL CENTER INC
Entity Type:Organization
Organization Name:WESTERN OHIO PODIATRIC MEDICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:MAHER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:937-548-1244
Mailing Address - Street 1:415 W RUSS RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45331-2457
Mailing Address - Country:US
Mailing Address - Phone:937-548-1244
Mailing Address - Fax:934-548-8898
Practice Address - Street 1:415 W RUSS RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:OH
Practice Address - Zip Code:45331-2457
Practice Address - Country:US
Practice Address - Phone:937-548-1244
Practice Address - Fax:934-548-8898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2413374Medicaid
OH0589470002Medicare NSC
OH9313831Medicare ID - Type Unspecified