Provider Demographics
NPI:1477554475
Name:WYANDOT MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:WYANDOT MEMORIAL HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:TY
Authorized Official - Middle Name:R
Authorized Official - Last Name:SHAULL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-294-4991
Mailing Address - Street 1:885 N SANDUSKY AVE
Mailing Address - Street 2:
Mailing Address - City:UPPER SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:43351-1031
Mailing Address - Country:US
Mailing Address - Phone:419-294-4991
Mailing Address - Fax:419-294-2233
Practice Address - Street 1:885 N SANDUSKY AVE
Practice Address - Street 2:
Practice Address - City:UPPER SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:43351-1031
Practice Address - Country:US
Practice Address - Phone:419-294-4991
Practice Address - Fax:419-092-0278
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-02
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000198227OtherANTHEM BC/BS
OH9687512Medicaid
=========OtherMEDICAL MUTUAL
OH9687512Medicaid