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NPI Code Detail

MEDICARE: MR. RONALD BOUDOURIS LISW

MEDICARE: MR. RONALD BOUDOURIS LISW
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
11041C0700XClinical Social Worker12263OH

General Provider Information

NPI Number : 1417992991
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. RONALD BOUDOURIS LISW
Provider Business Mailing Address
First Line : 1090 W SOUTH BOUNDARY ST
Second Line : STE 600
City : PERRYSBURG
State : OH
Zip : 43551-5249
Country : US
Telephone Number : 419-873-8280
Fax Number :
Provider Business Practice Location Address
First Line : 885 COMMERCE DR
Second Line :
City : PERRYSBURG
State : OH
Zip : 43551-5267
Country : US
Telephone Number : 419-330-1349
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/18/2006
Last Update Date : 05/05/2017

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