Provider Demographics
NPI:1962544635
Name:OHIO DEPARTMENT OF MENTAL RETARDATION AND DEVELOPMENTAL DISABILITIES
Entity type:Organization
Organization Name:OHIO DEPARTMENT OF MENTAL RETARDATION AND DEVELOPMENTAL DISABILITIES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-446-1642
Mailing Address - Street 1:30 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-3414
Mailing Address - Country:US
Mailing Address - Phone:614-466-1970
Mailing Address - Fax:614-466-3141
Practice Address - Street 1:2500 OHIO AVE
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631-1656
Practice Address - Country:US
Practice Address - Phone:740-446-1642
Practice Address - Fax:740-446-1341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0136025Medicaid
OH0280799Medicaid
OH0372618Medicaid
OHF04198Medicare UPIN
OH0136025Medicaid
OHE56419Medicare UPIN
OH9333788Medicare ID - Type UnspecifiedGROUP #