Basic Information
| Provider Information | |||||||||
| NPI: | 1083974489 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FIRELANDS REGIONAL MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FIRELANDS COUNSELING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1925 HAYES AVE | ||||||||
| Address2: | |||||||||
| City: | SANDUSKY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448704737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195575177 | ||||||||
| FaxNumber: | 4195575169 | ||||||||
| Practice Location | |||||||||
| Address1: | 1925 HAYES AVE | ||||||||
| Address2: | |||||||||
| City: | SANDUSKY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448704737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195575177 | ||||||||
| FaxNumber: | 4195575169 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2012 | ||||||||
| LastUpdateDate: | 09/24/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MONCHER | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT & CFO | ||||||||
| AuthorizedOfficialTelephone: | 4195577793 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | OH | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QR0405X | OH | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | 2916787 | 05 | OH | MEDICAID |