Basic Information
| Provider Information | |||||||||
| NPI: | 1316119019 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FIRELANDS REGIONAL MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1111 HAYES AVE | ||||||||
| Address2: | |||||||||
| City: | SANDUSKY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448703323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195577400 | ||||||||
| FaxNumber: | 4195575056 | ||||||||
| Practice Location | |||||||||
| Address1: | 1925 HAYES AVE | ||||||||
| Address2: | |||||||||
| City: | SANDUSKY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448704737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195575177 | ||||||||
| FaxNumber: | 4195575169 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2008 | ||||||||
| LastUpdateDate: | 09/24/2019 | ||||||||
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| AuthorizedOfficialLastName: | MONCHER | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT & CFO | ||||||||
| AuthorizedOfficialTelephone: | 4195577793 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 2497589 | 05 | OH | MEDICAID |