Provider Demographics
NPI:1689712879
Name:MARY RUTAN HOSPITAL
Entity Type:Organization
Organization Name:MARY RUTAN HOSPITAL
Other - Org Name:GENERAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP, FISCAL SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:CARMIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-592-4015
Mailing Address - Street 1:114 DOWELL AVE
Mailing Address - Street 2:
Mailing Address - City:BELLEFONTAINE
Mailing Address - State:OH
Mailing Address - Zip Code:43311-2305
Mailing Address - Country:US
Mailing Address - Phone:937-592-1099
Mailing Address - Fax:
Practice Address - Street 1:114 DOWELL AVE
Practice Address - Street 2:
Practice Address - City:BELLEFONTAINE
Practice Address - State:OH
Practice Address - Zip Code:43311-2305
Practice Address - Country:US
Practice Address - Phone:937-592-1099
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARY RUTAN HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-01
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH7607503Medicaid
OH7607503Medicaid