Provider Demographics
NPI:1255608519
Name:OHIO UNIVERSITY
Entity type:Organization
Organization Name:OHIO UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COORDINATOR OF CLINICAL SERVICES
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIANNE
Authorized Official - Middle Name:S
Authorized Official - Last Name:MALAWISTA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD,MA-CCC,SLP
Authorized Official - Phone:740-593-1418
Mailing Address - Street 1:W174 GROVER CENTER
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:OH
Mailing Address - Zip Code:45701
Mailing Address - Country:US
Mailing Address - Phone:740-593-1404
Mailing Address - Fax:740-593-4433
Practice Address - Street 1:W174 GROVER CENTER
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701
Practice Address - Country:US
Practice Address - Phone:740-593-1404
Practice Address - Fax:740-593-4433
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OHIO UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-11-30
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHA01437332B00000X, 332S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332S00000XSuppliersHearing Aid Equipment
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0058187Medicaid
OH000000246469OtherBLUE CROSS/BLUE SHIELD
OH9311251Medicare PIN