Provider Demographics
NPI:1578648895
Name:SAMUEL T. DETWILER, D.O. LLC
Entity Type:Organization
Organization Name:SAMUEL T. DETWILER, D.O. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:DETWILER
Authorized Official - Suffix:
Authorized Official - Credentials:DO LLC
Authorized Official - Phone:330-876-1111
Mailing Address - Street 1:8231 MAIN ST
Mailing Address - Street 2:PO BOX 99
Mailing Address - City:KINSMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44428-9514
Mailing Address - Country:US
Mailing Address - Phone:330-876-1111
Mailing Address - Fax:330-876-1005
Practice Address - Street 1:8231 MAIN ST
Practice Address - Street 2:
Practice Address - City:KINSMAN
Practice Address - State:OH
Practice Address - Zip Code:44428-9514
Practice Address - Country:US
Practice Address - Phone:330-876-1111
Practice Address - Fax:330-876-1005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2007-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-007985207Q00000X
OHNP-04053363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2760016Medicaid
OH2760016Medicaid
OHDA4565Medicare ID - Type UnspecifiedRAILROAD MEDICARE