Provider Demographics
NPI:1700098811
Name:MID-OHIO VALLEY PHYSICAL MEDICINE
Entity Type:Organization
Organization Name:MID-OHIO VALLEY PHYSICAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:LACEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:740-376-5044
Mailing Address - Street 1:400 MATTHEW STREET
Mailing Address - Street 2:SUITE 306
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750
Mailing Address - Country:US
Mailing Address - Phone:740-376-5044
Mailing Address - Fax:740-374-1792
Practice Address - Street 1:400 MATTHEW STREET
Practice Address - Street 2:SUITE 306
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750
Practice Address - Country:US
Practice Address - Phone:740-376-5044
Practice Address - Fax:740-374-1792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35066931L208100000X, 2081P0004X, 2081S0010X, 2084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
No2081P0004XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSpinal Cord Injury MedicineGroup - Single Specialty
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Single Specialty
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical NeurophysiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHL0982950Medicaid
WV0113577000Medicaid
WV0113577000Medicaid