Healthcare Provider Details

I. General information

NPI: 1124159686
Provider Name (Legal Business Name): HARRY M HUMENIUK MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 10/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4935 HARROUN RD
SYLVANIA OH
43560-2107
US

IV. Provider business mailing address

4935 HARROUN RD
SYLVANIA OH
43560-2107
US

V. Phone/Fax

Practice location:
  • Phone: 419-885-7546
  • Fax: 419-882-4969
Mailing address:
  • Phone: 419-885-7546
  • Fax: 419-882-4969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number35061843
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34007965B
License Number StateOH

VIII. Authorized Official

Name: DR. HARRY MICHAEL HUMENIUK
Title or Position: OWNER, PRESIDENT
Credential: M.D.
Phone: 419-886-7546