Provider Demographics
NPI:1205909561
Name:GRANTRIVERSIDE MEDICAL CARE FOUNDATION, INC
Entity type:Organization
Organization Name:GRANTRIVERSIDE MEDICAL CARE FOUNDATION, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:WUESTEWALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-566-5643
Mailing Address - Street 1:5350 FRANTZ RD
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43016-4259
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3545 OLENTANGY RIVER RD
Practice Address - Street 2:STE 501
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-3907
Practice Address - Country:US
Practice Address - Phone:614-566-2714
Practice Address - Fax:614-566-2712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPENDINGMedicaid
OHPENDINGMedicaid