Provider Demographics
NPI:1316126576
Name:WAYNE INTERNAL MEDICINE
Entity type:Organization
Organization Name:WAYNE INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:OSAMA
Authorized Official - Middle Name:
Authorized Official - Last Name:MITRI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-262-1700
Mailing Address - Street 1:PO BOX 1206
Mailing Address - Street 2:
Mailing Address - City:WOOSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44691-7083
Mailing Address - Country:US
Mailing Address - Phone:330-262-1700
Mailing Address - Fax:330-345-8980
Practice Address - Street 1:128 EAST MILLTOWN ROAD
Practice Address - Street 2:SUITE 101
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691-6109
Practice Address - Country:US
Practice Address - Phone:330-262-1700
Practice Address - Fax:330-345-8980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-24
Last Update Date:2007-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35077131207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000279626OtherANTHEM
OH000000279626OtherANTHEM
OHWA9334001Medicare PIN