Healthcare Provider Details

I. General information

NPI: 1699698571
Provider Name (Legal Business Name): BLUE WILLOW MEDICAL TRANSPORT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2026
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1053 OAK ST
MEDINA OH
44256-4043
US

IV. Provider business mailing address

1053 OAK ST
MEDINA OH
44256-4043
US

V. Phone/Fax

Practice location:
  • Phone: 216-765-1011
  • Fax: 216-765-1011
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: HADIA MANDENIN FANY
Title or Position: CEO
Credential: DIOP
Phone: 216-765-1011