Provider Demographics
NPI:1487953634
Name:MEDETC LLC
Entity type:Organization
Organization Name:MEDETC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:WALDRON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-303-3466
Mailing Address - Street 1:2718 CAROLYN DR
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45807-2310
Mailing Address - Country:US
Mailing Address - Phone:419-302-3337
Mailing Address - Fax:
Practice Address - Street 1:2718 CAROLYN DR
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45807-2310
Practice Address - Country:US
Practice Address - Phone:419-302-3337
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-26
Last Update Date:2011-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35052128207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHA82368Medicare UPIN