Healthcare Provider Details

I. General information

NPI: 1700098811
Provider Name (Legal Business Name): MID-OHIO VALLEY PHYSICAL MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 07/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 MATTHEW STREET SUITE 306
MARIETTA OH
45750
US

IV. Provider business mailing address

400 MATTHEW STREET SUITE 306
MARIETTA OH
45750
US

V. Phone/Fax

Practice location:
  • Phone: 740-376-5044
  • Fax: 740-374-1792
Mailing address:
  • Phone: 740-376-5044
  • Fax: 740-374-1792

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P0004X
TaxonomySpinal Cord Injury Medicine Physician
License Number35066931L
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number35066931L
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number35066931L
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number35066931L
License Number StateOH

VIII. Authorized Official

Name: DAVID WILLIAM LACEY
Title or Position: PRESIDENT
Credential: M.D.
Phone: 740-376-5044