Provider Demographics
NPI:1700987229
Name:PHYSICIANS DIAGNOSTIC & REHABILITATION CENTER OF WARREN IN
Entity Type:Organization
Organization Name:PHYSICIANS DIAGNOSTIC & REHABILITATION CENTER OF WARREN IN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:P
Authorized Official - Last Name:FARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:330-372-5550
Mailing Address - Street 1:PO BOX 14465
Mailing Address - Street 2:
Mailing Address - City:POLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44514-7465
Mailing Address - Country:US
Mailing Address - Phone:330-372-5550
Mailing Address - Fax:330-372-5551
Practice Address - Street 1:2048 N RIVER RD NE # 3
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44483-2530
Practice Address - Country:US
Practice Address - Phone:330-372-5550
Practice Address - Fax:330-372-5551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3569111NR0200X
OH34.002093208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No111NR0200XChiropractic ProvidersChiropractorRadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2459307Medicaid
OH=========-00OtherWORKMAN'S COMPENSATION
5324240001Medicare NSC
OH2459307Medicaid