Healthcare Provider Details

I. General information

NPI: 1154318467
Provider Name (Legal Business Name): TOM WIRTH BARTSOKAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 03/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 WAYNE ST SUITE 100
MARIETTA OH
45750-3300
US

IV. Provider business mailing address

PO BOX 449
MARIETTA OH
45750-0449
US

V. Phone/Fax

Practice location:
  • Phone: 740-374-6030
  • Fax: 740-374-6029
Mailing address:
  • Phone: 740-374-4500
  • Fax: 740-374-5887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number35.052565
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: