Provider Demographics
NPI:1992996524
Name:WAUSEON CLINIC CORP
Entity type:Organization
Organization Name:WAUSEON CLINIC CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:GRIESER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-335-7921
Mailing Address - Street 1:PO BOX 418
Mailing Address - Street 2:
Mailing Address - City:WAUSEON
Mailing Address - State:OH
Mailing Address - Zip Code:43567-0418
Mailing Address - Country:US
Mailing Address - Phone:419-335-7921
Mailing Address - Fax:419-337-5988
Practice Address - Street 1:495 S SHOOP AVE
Practice Address - Street 2:
Practice Address - City:WAUSEON
Practice Address - State:OH
Practice Address - Zip Code:43567-1719
Practice Address - Country:US
Practice Address - Phone:419-335-7921
Practice Address - Fax:419-337-5988
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-08
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0646340Medicaid
OH9922861Medicare PIN