Provider Demographics
NPI:1619298924
Name:PAULDING MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:PAULDING MEDICAL CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:FREDERIC
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:HENDRICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:419-399-2630
Mailing Address - Street 1:11550 STATE ROUTE 500
Mailing Address - Street 2:
Mailing Address - City:PAULDING
Mailing Address - State:OH
Mailing Address - Zip Code:45879-9173
Mailing Address - Country:US
Mailing Address - Phone:419-399-2630
Mailing Address - Fax:419-399-3039
Practice Address - Street 1:11550 STATE ROUTE 500
Practice Address - Street 2:
Practice Address - City:PAULDING
Practice Address - State:OH
Practice Address - Zip Code:45879-9173
Practice Address - Country:US
Practice Address - Phone:419-399-2630
Practice Address - Fax:419-399-3039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-21
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-005455208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0853170Medicaid
OH0853170Medicaid
OHHE0174171Medicare PIN