MEDICARE: RYAN JACOB PODACH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	374U00000X	Home Health Aide

General Provider Information

NPI Number	:	1174867568
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RYAN JACOB PODACH

Provider Business Mailing Address
First Line	:	PO BOX 26
Second Line	:
City	:	BLOOMDALE
State	:	OH
Zip	:	44817-0026
Country	:	US
Telephone Number	:	419-619-1375
Fax Number	:

Provider Business Practice Location Address
First Line	:	212 N MAPLE ST
Second Line	:
City	:	BLOOMDALE
State	:	OH
Zip	:	44817-0026
Country	:	US
Telephone Number	:	419-619-1375
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/26/2012
Last Update Date	:	11/26/2012

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