Provider Demographics
NPI:1821275546
Name:PERRYSBURG REHABILITATION LLC
Entity Type:Organization
Organization Name:PERRYSBURG REHABILITATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:M
Authorized Official - Last Name:BREEN
Authorized Official - Suffix:
Authorized Official - Credentials:LPT
Authorized Official - Phone:419-897-9265
Mailing Address - Street 1:1900 INDIAN WOOD CIR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-4033
Mailing Address - Country:US
Mailing Address - Phone:419-897-9265
Mailing Address - Fax:419-897-0544
Practice Address - Street 1:1900 INDIAN WOOD CIR
Practice Address - Street 2:SUITE 100
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-4033
Practice Address - Country:US
Practice Address - Phone:419-897-9265
Practice Address - Fax:419-897-0544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-24
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT007350208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2188127Medicaid
OH2188127Medicaid