Provider Demographics
NPI:1386826766
Name:WAVERLY MEDICAL PRACTICE,INC.
Entity Type:Organization
Organization Name:WAVERLY MEDICAL PRACTICE,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:ARTHUR
Authorized Official - Last Name:WILKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:740-947-2383
Mailing Address - Street 1:207 SAINT ANNS LN
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:OH
Mailing Address - Zip Code:45690-1040
Mailing Address - Country:US
Mailing Address - Phone:740-708-5478
Mailing Address - Fax:740-947-5720
Practice Address - Street 1:207 ST ANNS LN
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:OH
Practice Address - Zip Code:45690-1040
Practice Address - Country:US
Practice Address - Phone:740-708-5478
Practice Address - Fax:740-947-5720
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35024770261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9470880Medicaid
OHA70599Medicare UPIN
OH9470880Medicaid