Provider Demographics
NPI:1134189475
Name:MARY RUTAN HOSPITAL
Entity type:Organization
Organization Name:MARY RUTAN HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP/FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:RON
Authorized Official - Middle Name:
Authorized Official - Last Name:CARMIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-592-4015
Mailing Address - Street 1:2231 TIMBER TRL
Mailing Address - Street 2:
Mailing Address - City:BELLEFONTAINE
Mailing Address - State:OH
Mailing Address - Zip Code:43311-9036
Mailing Address - Country:US
Mailing Address - Phone:937-599-3115
Mailing Address - Fax:937-592-5285
Practice Address - Street 1:2231 TIMBER TRL
Practice Address - Street 2:
Practice Address - City:BELLEFONTAINE
Practice Address - State:OH
Practice Address - Zip Code:43311-9036
Practice Address - Country:US
Practice Address - Phone:937-599-3115
Practice Address - Fax:937-592-5285
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARY RUTAN HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-03-23
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH7607503Medicaid
OH7607503Medicaid