Provider Demographics
NPI:1770766578
Name:DEFIANCE REGIONAL MEDICAL CENTER
Entity type:Organization
Organization Name:DEFIANCE REGIONAL MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR VP
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:WACHSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-824-7580
Mailing Address - Street 1:1200 RALSTON AVE
Mailing Address - Street 2:
Mailing Address - City:DEFIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:43512-1396
Mailing Address - Country:US
Mailing Address - Phone:800-477-4035
Mailing Address - Fax:
Practice Address - Street 1:1200 RALSTON AVE
Practice Address - Street 2:
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512-1396
Practice Address - Country:US
Practice Address - Phone:800-477-4035
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DEFIANCE REGIONAL MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-14
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1160261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH========= 177OtherMEDICAL MUTUAL
361328Medicare Oscar/Certification