Provider Demographics
NPI:1124369350
Name:VAN WERT MEDICAL SERVICES, LTD.
Entity type:Organization
Organization Name:VAN WERT MEDICAL SERVICES, LTD.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP FISCAL & ADMINISTRATIVE SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:HOLLIDAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-238-2390
Mailing Address - Street 1:140 FOX RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:VAN WERT
Mailing Address - State:OH
Mailing Address - Zip Code:45891-2475
Mailing Address - Country:US
Mailing Address - Phone:419-238-6735
Mailing Address - Fax:419-232-5271
Practice Address - Street 1:140 FOX RD
Practice Address - Street 2:SUITE 104
Practice Address - City:VAN WERT
Practice Address - State:OH
Practice Address - Zip Code:45891-2475
Practice Address - Country:US
Practice Address - Phone:419-232-5291
Practice Address - Fax:419-232-5292
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VAN WERT MEDICAL SERVICES, LTD.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-03-13
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208D00000X
OH36003593213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH101850Medicare PIN
OH9358831Medicare PIN