Provider Demographics
NPI:1679758205
Name:WYANDOT MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:WYANDOT MEMORIAL HOSPITAL
Other - Org Name:WYANDOT MEMORIAL HOSPITAL EMERGENCY ROOM
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:D'ETTORRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-294-4991
Mailing Address - Street 1:885 N SANDUSKY AVE
Mailing Address - Street 2:
Mailing Address - City:UPPER SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:43351-1031
Mailing Address - Country:US
Mailing Address - Phone:419-294-4991
Mailing Address - Fax:419-294-2233
Practice Address - Street 1:885 N SANDUSKY AVE
Practice Address - Street 2:
Practice Address - City:UPPER SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:43351-1031
Practice Address - Country:US
Practice Address - Phone:419-294-4991
Practice Address - Fax:419-294-2233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-02
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1296207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9687512Medicaid
OH361329Medicare PIN