Provider Demographics
NPI:1952586075
Name:HEALTH SOURCE OF WARREN, INC.
Entity Type:Organization
Organization Name:HEALTH SOURCE OF WARREN, INC.
Other - Org Name:HEALTHSOURCE OF SOUTH TOLEDO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSOCIATE
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:RILEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:419-720-1472
Mailing Address - Street 1:4400 HEATHERDOWNS BLVD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-3147
Mailing Address - Country:US
Mailing Address - Phone:419-720-1472
Mailing Address - Fax:419-720-1475
Practice Address - Street 1:4400 HEATHERDOWNS BLVD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614-3147
Practice Address - Country:US
Practice Address - Phone:419-720-1472
Practice Address - Fax:419-720-1475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-08
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2743261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHU76640Medicare UPIN