Healthcare Provider Details

I. General information

NPI: 1144418260
Provider Name (Legal Business Name): FAMILY PRACTICE ASSOCIATES OF ANTWERP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2007
Last Update Date: 10/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

422 W RIVER ST
ANTWERP OH
45813-8417
US

IV. Provider business mailing address

422 W RIVER ST
ANTWERP OH
45813-8417
US

V. Phone/Fax

Practice location:
  • Phone: 419-258-5195
  • Fax: 419-258-2620
Mailing address:
  • Phone: 419-258-5195
  • Fax: 419-258-2620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TODD MICHAEL WILEY
Title or Position: PHYSICIAN/OWNER
Credential: MD
Phone: 419-258-5195