Provider Demographics
NPI:1750374070
Name:GENOA MEDICAL CENTER
Entity type:Organization
Organization Name:GENOA MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF CORPORATION
Authorized Official - Prefix:DR
Authorized Official - First Name:NEIMAN
Authorized Official - Middle Name:TOUFEK
Authorized Official - Last Name:ODEH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:419-855-7772
Mailing Address - Street 1:22614 W STATE ROUTE 51
Mailing Address - Street 2:
Mailing Address - City:GENOA
Mailing Address - State:OH
Mailing Address - Zip Code:43430-1143
Mailing Address - Country:US
Mailing Address - Phone:419-855-7772
Mailing Address - Fax:419-855-4800
Practice Address - Street 1:22614 W STATE ROUTE 51
Practice Address - Street 2:
Practice Address - City:GENOA
Practice Address - State:OH
Practice Address - Zip Code:43430-1143
Practice Address - Country:US
Practice Address - Phone:419-855-7772
Practice Address - Fax:419-855-4800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-23
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35075834207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2169059Medicaid
OH9309221Medicare PIN