Provider Demographics
NPI:1821148404
Name:WOODSIDE MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:WOODSIDE MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:EXTEN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:419-756-2003
Mailing Address - Street 1:475 LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44907-1501
Mailing Address - Country:US
Mailing Address - Phone:419-756-2003
Mailing Address - Fax:419-756-3637
Practice Address - Street 1:475 LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44907-1501
Practice Address - Country:US
Practice Address - Phone:419-756-2003
Practice Address - Fax:419-756-3637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
9307241Medicare ID - Type UnspecifiedMEDICARE