Provider Demographics
NPI:1376671065
Name:COMMUNITY HOSPITALS AND WELLNESS CENTERS INTERNAL MEDICINE CLINIC
Entity Type:Organization
Organization Name:COMMUNITY HOSPITALS AND WELLNESS CENTERS INTERNAL MEDICINE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:L
Authorized Official - Last Name:ENNEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-636-1131
Mailing Address - Street 1:447 N SHOOP AVE
Mailing Address - Street 2:
Mailing Address - City:WAUSEON
Mailing Address - State:OH
Mailing Address - Zip Code:43567-1261
Mailing Address - Country:US
Mailing Address - Phone:419-337-7980
Mailing Address - Fax:419-337-8265
Practice Address - Street 1:447 N SHOOP AVE
Practice Address - Street 2:
Practice Address - City:WAUSEON
Practice Address - State:OH
Practice Address - Zip Code:43567-1261
Practice Address - Country:US
Practice Address - Phone:419-337-7980
Practice Address - Fax:419-337-8265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9331401Medicare ID - Type UnspecifiedPHYSICIAN BILLING