Provider Demographics
NPI:1588862163
Name:MANTUA FAMILY HEALTHCARE
Entity type:Organization
Organization Name:MANTUA FAMILY HEALTHCARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANN
Authorized Official - Middle Name:C
Authorized Official - Last Name:WELDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-861-3451
Mailing Address - Street 1:PO BOX 140333
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-0333
Mailing Address - Country:US
Mailing Address - Phone:419-861-3451
Mailing Address - Fax:419-861-3451
Practice Address - Street 1:6693 N CHESTNUT ST
Practice Address - Street 2:10A&B
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-3922
Practice Address - Country:US
Practice Address - Phone:419-861-3451
Practice Address - Fax:419-861-3451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35052329W207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000134223OtherANTHEM
OH01594OtherFAA
OH100766OtherKAISER
OHQ015911AOtherHOMETOWN
OH0649249Medicaid
OH314502699-00OtherBWC
OH100766OtherKAISER
OHQ015911AOtherHOMETOWN
OHA16742Medicare UPIN