Provider Demographics
NPI:1548974009
Name:COUNTRYSIDE ACUTE CARE LLC
Entity type:Organization
Organization Name:COUNTRYSIDE ACUTE CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:MARPLE
Authorized Official - Suffix:
Authorized Official - Credentials:FNP, RN, PARAMEDIC
Authorized Official - Phone:937-605-9294
Mailing Address - Street 1:931 WILSON RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH VIENNA
Mailing Address - State:OH
Mailing Address - Zip Code:45369-9747
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:MAIN ST
Practice Address - Street 2:
Practice Address - City:SOUTH VIENNA
Practice Address - State:OH
Practice Address - Zip Code:45369
Practice Address - Country:US
Practice Address - Phone:937-000-0000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-10
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty