Provider Demographics
NPI:1215936075
Name:UPPER SANDUSKY MEDICAL ASSOC INC
Entity type:Organization
Organization Name:UPPER SANDUSKY MEDICAL ASSOC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATION PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KONSTANTINE
Authorized Official - Middle Name:K
Authorized Official - Last Name:SOLACOFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-294-2375
Mailing Address - Street 1:777 N SANDUSKY AVE
Mailing Address - Street 2:
Mailing Address - City:UPPER SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:43351-1075
Mailing Address - Country:US
Mailing Address - Phone:419-294-2375
Mailing Address - Fax:419-294-2412
Practice Address - Street 1:777 N SANDUSKY AVE
Practice Address - Street 2:
Practice Address - City:UPPER SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:43351-1075
Practice Address - Country:US
Practice Address - Phone:419-294-2375
Practice Address - Fax:419-294-2412
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0423652Medicaid
OH0423652Medicaid