Provider Demographics
NPI:1952432551
Name:SURGICAL SPECIALISTS OF WAYNE COUNTY, LLC
Entity Type:Organization
Organization Name:SURGICAL SPECIALISTS OF WAYNE COUNTY, LLC
Other - Org Name:SURGICAL SPECIALISTS OF WAYNE COUNTY
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:CASTELLUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-374-9614
Mailing Address - Street 1:3540 BURBANK RD # 127
Mailing Address - Street 2:
Mailing Address - City:WOOSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44691-8539
Mailing Address - Country:US
Mailing Address - Phone:330-465-4429
Mailing Address - Fax:
Practice Address - Street 1:1761 BEALL AVE
Practice Address - Street 2:
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691-2342
Practice Address - Country:US
Practice Address - Phone:330-263-8759
Practice Address - Fax:330-263-8259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2024-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0167055Medicaid
OHD50844Medicare UPIN
OH0167055Medicaid