Provider Demographics
NPI:1518940881
Name:ANTHONY WAYNE FAMILY PRACTICE INC
Entity Type:Organization
Organization Name:ANTHONY WAYNE FAMILY PRACTICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:419-897-2270
Mailing Address - Street 1:5757 MONCLOVA RD
Mailing Address - Street 2:STE 24
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537
Mailing Address - Country:US
Mailing Address - Phone:419-897-2270
Mailing Address - Fax:419-897-2290
Practice Address - Street 1:5757 MONCLOVA RD
Practice Address - Street 2:STE 24
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537
Practice Address - Country:US
Practice Address - Phone:419-897-2290
Practice Address - Fax:419-897-2290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-21
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34004231M207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000142183OtherANTHEM BCBS
OH0904927Medicaid
OH02111OtherPARAMOUNT HEALTH CARE
OH236966123010OtherMEDICAL MUTUAL OF OHIO
OH236966123OtherTRICARE
OH080155060OtherPALMETTO GBA RAILROAD MED
F47334Medicare UPIN
OH0730896Medicare ID - Type Unspecified