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General NPI Number Information
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NPI Number | 1700098811
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Entity Type | Organization
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Legal Business Name | MID-OHIO VALLEY PHYSICAL MEDICINE
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Dates
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Enumeration Date | 05/03/2007
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Last Update Date | 07/17/2007
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Provider Practice Location Address
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Address Line | 400 MATTHEW STREET SUITE 306
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City | MARIETTA
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State | OH
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Zip | 45750
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Country | US
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Telephone | 740-376-5044
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Fax | 740-374-1792
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Provider Business Mailing Address
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Address Line | 400 MATTHEW STREET SUITE 306
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City | MARIETTA
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State | OH
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Zip | 45750
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Country | US
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Telephone | 740-376-5044
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Fax | 740-374-1792
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Authorized Official
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Title or Position | PRESIDENT
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Name | DAVID WILLIAM LACEY
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Credential | M.D.
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Telephone | 740-376-5044
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2081P0004X
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Taxonomy Name | Spinal Cord Injury Medicine Physician
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License Number | 35066931L
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 2081S0010X
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Taxonomy Name | Sports Medicine (Physical Medicine & Rehabilitation) Physician
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License Number | 35066931L
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License Number State | OH
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Taxonomy #3
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Taxonomy Code | 2084N0600X
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Taxonomy Name | Clinical Neurophysiology Physician
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License Number | 35066931L
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License Number State | OH
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Taxonomy #4
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number | 35066931L
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License Number State | OH
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