Provider Demographics
NPI:1306988357
Name:VILLAGE OF SHERRODSVILLE
Entity type:Organization
Organization Name:VILLAGE OF SHERRODSVILLE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FISCAL OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:ROXANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAZUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-269-5025
Mailing Address - Street 1:PO BOX 31
Mailing Address - Street 2:
Mailing Address - City:SHERRODSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44675-0031
Mailing Address - Country:US
Mailing Address - Phone:740-269-5025
Mailing Address - Fax:
Practice Address - Street 1:4 SHERROD AVE
Practice Address - Street 2:
Practice Address - City:SHERRODSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44675
Practice Address - Country:US
Practice Address - Phone:740-269-5025
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VILLAGE OF SHERRODSVILLE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-13
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH021016900341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0541024Medicaid
OH000000229642OtherBCBS
OH=========001OtherMEDICAL MUTUAL
OH9152081Medicare PIN
OH590009254Medicare PIN