Provider Demographics
NPI:1962501627
Name:BLANCHARD VALLEY MEDICAL PRACTICE LLC
Entity Type:Organization
Organization Name:BLANCHARD VALLEY MEDICAL PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:CYTLAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:4194-423-5497
Mailing Address - Street 1:1900 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FINDLAY
Mailing Address - State:OH
Mailing Address - Zip Code:45840-1214
Mailing Address - Country:US
Mailing Address - Phone:419-423-4500
Mailing Address - Fax:419-423-5550
Practice Address - Street 1:1900 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:FINDLAY
Practice Address - State:OH
Practice Address - Zip Code:45840-1239
Practice Address - Country:US
Practice Address - Phone:419-423-4500
Practice Address - Fax:419-423-5550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 207R00000X, 207RE0101X, 207RP1001X, 207V00000X, 208000000X, 363LF0000X
OH350887922084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHDD9723OtherRAILROAD GROUP
OH2602544Medicaid
OH2602544Medicaid