Provider Demographics
NPI:1396816708
Name:SANDUSKY FAMILY PRACTICE INC
Entity Type:Organization
Organization Name:SANDUSKY FAMILY PRACTICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:JEFFERSON
Authorized Official - Last Name:WYSOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-625-4461
Mailing Address - Street 1:3103 CAMPBELL ST
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-7230
Mailing Address - Country:US
Mailing Address - Phone:419-625-4461
Mailing Address - Fax:419-625-5199
Practice Address - Street 1:3103 CAMPBELL ST
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-7230
Practice Address - Country:US
Practice Address - Phone:419-625-4461
Practice Address - Fax:419-625-5199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-047619207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000131843OtherANTHEM
OH04375OtherPARAMOUNT
OH20636020100OtherBWC
OH0538681Medicaid
OH206360201001OtherMED MUTUAL OF OHIO
OH04375OtherPARAMOUNT
OHWY0516683Medicare ID - Type Unspecified