Provider Demographics
NPI:1467994541
Name:VAN WERT MEDICAL SERVICES, LTD.
Entity Type:Organization
Organization Name:VAN WERT MEDICAL SERVICES, LTD.
Other - Org Name:VAN WERT MEDICAL SERVICES, LTD. SPECIALTY
Other - Org Type:Other Name
Authorized Official - Title/Position:FISCAL & ADMINISTRATIVE SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLIDAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-238-2390
Mailing Address - Street 1:140 FOX RD
Mailing Address - Street 2:STE 202
Mailing Address - City:VAN WERT
Mailing Address - State:OH
Mailing Address - Zip Code:45891-2475
Mailing Address - Country:US
Mailing Address - Phone:419-238-6735
Mailing Address - Fax:419-232-5271
Practice Address - Street 1:140 FOX RD
Practice Address - Street 2:STE 209
Practice Address - City:VAN WERT
Practice Address - State:OH
Practice Address - Zip Code:45891-2475
Practice Address - Country:US
Practice Address - Phone:419-238-8621
Practice Address - Fax:419-238-0424
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VAN WERT MEDICAL SERVICES, LTD.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-11-07
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36002056213EP1101X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2641903Medicaid
OH9358831Medicare PIN
OH7421041Medicare PIN