Provider Demographics
NPI:1306898457
Name:AMENDT, WAYNE C (MD)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:C
Last Name:AMENDT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1560
Mailing Address - Country:US
Mailing Address - Phone:740-395-8805
Mailing Address - Fax:740-395-8855
Practice Address - Street 1:280 PATTONSVILLE RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:OH
Practice Address - Zip Code:45640-9452
Practice Address - Country:US
Practice Address - Phone:740-395-8805
Practice Address - Fax:740-395-8855
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-05-2501207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0836288OtherMOLINA MEDICAID
200039910OtherRR MEDICARE
000000192900OtherANTHEM BCBS
OH0836288Medicaid
WV1801677000Medicaid
OH000000181661OtherUNISON MEDICAID
OH310917085086OtherCARESOURCE MEDICAID
001714122OtherMOUNTAIN STATE BCBS
WV4039442Medicare PIN
E29534Medicare UPIN
WV1801677000Medicaid