Provider Demographics
NPI:1477748325
Name:ELYRIA OBSTETRICS & GYNECOLOGY INC
Entity Type:Organization
Organization Name:ELYRIA OBSTETRICS & GYNECOLOGY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:E
Authorized Official - Last Name:WISLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:440-329-7330
Mailing Address - Street 1:PO BOX 1966
Mailing Address - Street 2:
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44036-1966
Mailing Address - Country:US
Mailing Address - Phone:440-329-7330
Mailing Address - Fax:
Practice Address - Street 1:125 E BROAD ST
Practice Address - Street 2:SUITE 302
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-6400
Practice Address - Country:US
Practice Address - Phone:440-329-7330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-12
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0632186Medicaid
OH0632186Medicaid
OH0632186Medicaid