Provider Demographics
NPI:1740481746
Name:WOODLAND CLINIC, INC.
Entity type:Organization
Organization Name:WOODLAND CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:HUNT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:4405-937-3690
Mailing Address - Street 1:106 GATEWAY AVE
Mailing Address - Street 2:
Mailing Address - City:CONNEAUT
Mailing Address - State:OH
Mailing Address - Zip Code:44030-2349
Mailing Address - Country:US
Mailing Address - Phone:440-593-7360
Mailing Address - Fax:440-593-6407
Practice Address - Street 1:106 GATEWAY AVE
Practice Address - Street 2:
Practice Address - City:CONNEAUT
Practice Address - State:OH
Practice Address - Zip Code:44030-2349
Practice Address - Country:US
Practice Address - Phone:440-593-7360
Practice Address - Fax:440-593-6407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP04998363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2751517Medicaid
OH9368971Medicare PIN
OH2751517Medicaid