Provider Demographics
NPI:1295916146
Name:WYCHOCK PHYSICAL THERAPY INC
Entity type:Organization
Organization Name:WYCHOCK PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:G
Authorized Official - Last Name:WYCHOCK
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICAL THERAPIST
Authorized Official - Phone:440-964-2035
Mailing Address - Street 1:607 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004-3262
Mailing Address - Country:US
Mailing Address - Phone:440-964-2035
Mailing Address - Fax:440-964-0699
Practice Address - Street 1:607 LAKE AVE
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-3262
Practice Address - Country:US
Practice Address - Phone:440-964-2035
Practice Address - Fax:440-964-0699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-20
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT006573174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2361699Medicaid
OHDA9882OtherRETIRED RAILROAD MEDICARE
OH000000320301OtherBLUE CROSS BLUE SHIELD
OH9343311Medicare PIN