Provider Demographics
NPI:1144418260
Name:FAMILY PRACTICE ASSOCIATES OF ANTWERP
Entity type:Organization
Organization Name:FAMILY PRACTICE ASSOCIATES OF ANTWERP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:WILEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-258-5195
Mailing Address - Street 1:422 W RIVER ST
Mailing Address - Street 2:
Mailing Address - City:ANTWERP
Mailing Address - State:OH
Mailing Address - Zip Code:45813-8417
Mailing Address - Country:US
Mailing Address - Phone:419-258-5195
Mailing Address - Fax:419-258-2620
Practice Address - Street 1:422 W RIVER ST
Practice Address - Street 2:
Practice Address - City:ANTWERP
Practice Address - State:OH
Practice Address - Zip Code:45813-8417
Practice Address - Country:US
Practice Address - Phone:419-258-5195
Practice Address - Fax:419-258-2620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-15
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHFA9321901Medicare PIN