Provider Demographics
| NPI: | 1942268735 |
|---|---|
| Name: | VAN WERT MEDICAL SERVICES, LTD. |
| Entity Type: | Organization |
| Organization Name: | VAN WERT MEDICAL SERVICES, LTD. |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | VICE PRESIDENT |
| Authorized Official - Prefix: | MR |
| Authorized Official - First Name: | MICHAEL |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | HOLLIDAY |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 419-238-8285 |
| Mailing Address - Street 1: | 1250 S WASHINGTON ST |
| Mailing Address - Street 2: | |
| Mailing Address - City: | VAN WERT |
| Mailing Address - State: | OH |
| Mailing Address - Zip Code: | 45891-2551 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 419-238-6735 |
| Mailing Address - Fax: | 419-232-5271 |
| Practice Address - Street 1: | 140 FOX RD |
| Practice Address - Street 2: | STE 201 |
| Practice Address - City: | VAN WERT |
| Practice Address - State: | OH |
| Practice Address - Zip Code: | 45891-2475 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 419-238-6735 |
| Practice Address - Fax: | 419-232-5271 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | Yes |
| Parent Organization LBN: | VAN WERT COUNTY HOSPITAL |
| Parent Organization TIN: | <UNAVAIL> |
| Enumeration Date: | 2006-05-02 |
| Last Update Date: | 2017-05-01 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| OH | 35-07-8450-M | 207Q00000X |
| OH | 35048258 | 207Q00000X |
| OH | 35-06-3622 | 207R00000X |
| OH | 35058390 | 207VF0040X |
| OH | 35128002 | 207VG0400X |
| OH | 35121140 | 207VX0000X |
| OH | 35086105 | 2080A0000X |
| OH | 208100000X | |
| OH | 35071740 | 208600000X |
| OH | 35063622 | 208M00000X |
| OH | 35089010 | 208M00000X |
| OH | 36003593 | 213ES0103X |
| OH | 36002056 | 213ES0103X |
| OH | NP07379 | 363L00000X |
| OH | NP08410 | 363LF0000X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 207VF0040X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Female Pelvic Medicine and Reconstructive Surgery | Group - Multi-Specialty |
| No | 207VG0400X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | Group - Multi-Specialty |
| No | 207VX0000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Obstetrics | Group - Multi-Specialty |
| No | 2080A0000X | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine | Group - Multi-Specialty |
| No | 208100000X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Group - Multi-Specialty | |
| No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
| No | 208M00000X | Allopathic & Osteopathic Physicians | Hospitalist | Group - Multi-Specialty | |
| No | 213ES0103X | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | Group - Multi-Specialty |
| No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty | |
| No | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| OH | 2641903 | Medicaid | |
| OH | 9358831 | Medicare PIN | |
| OH | VA9358831 | Medicare ID - Type Unspecified | MEDICARE GROUP NUMBER |
