Provider Demographics
NPI:1588654230
Name:AUGLAIZE FAMILY PRACTICE CENTER LLC
Entity Type:Organization
Organization Name:AUGLAIZE FAMILY PRACTICE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:HOYT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-738-9680
Mailing Address - Street 1:PO BOX 359
Mailing Address - Street 2:
Mailing Address - City:WAPAKONETA
Mailing Address - State:OH
Mailing Address - Zip Code:45895-0359
Mailing Address - Country:US
Mailing Address - Phone:419-738-9601
Mailing Address - Fax:419-941-1368
Practice Address - Street 1:1007 W AUGLAIZE ST
Practice Address - Street 2:
Practice Address - City:WAPAKONETA
Practice Address - State:OH
Practice Address - Zip Code:45895-1351
Practice Address - Country:US
Practice Address - Phone:419-738-9601
Practice Address - Fax:419-941-1368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-25
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2136861Medicaid
OH2136861Medicaid