Provider Demographics
NPI:1962775767
Name:MAUMEE VALLEY INTERNIST INC
Entity type:Organization
Organization Name:MAUMEE VALLEY INTERNIST INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THURAI
Authorized Official - Middle Name:Y
Authorized Official - Last Name:KUMARAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-352-2105
Mailing Address - Street 1:960 W WOOSTER ST STE 205
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-2650
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:960 W WOOSTER ST STE 205
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-2650
Practice Address - Country:US
Practice Address - Phone:419-352-2105
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-10
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH07353898207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2053745Medicaid
OHG65239Medicare UPIN
OH2053745Medicaid