Provider Demographics
NPI:1265436927
Name:WATERVILLE FAMILY PHYSICIANS INC.
Entity type:Organization
Organization Name:WATERVILLE FAMILY PHYSICIANS INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:BRUSS
Authorized Official - Suffix:I
Authorized Official - Credentials:MD
Authorized Official - Phone:419-878-2026
Mailing Address - Street 1:900 WATERVILLE MONCLOVA RD
Mailing Address - Street 2:STE A
Mailing Address - City:WATERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43566-1169
Mailing Address - Country:US
Mailing Address - Phone:419-878-2026
Mailing Address - Fax:419-878-3236
Practice Address - Street 1:900 WATERVILLE MONCLOVA RD
Practice Address - Street 2:STE A
Practice Address - City:WATERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43566-1169
Practice Address - Country:US
Practice Address - Phone:419-878-2026
Practice Address - Fax:419-878-3236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH00539321207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2281909Medicaid
OHCC0115OtherRR MEDICARE
OH=========1200OtherMEDICAL MUTUAL
OH2281909Medicaid