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NPI Code Detail

MEDICARE: WOODSIDE MEDICAL GROUP, INC.

MEDICARE: WOODSIDE MEDICAL GROUP, INC.
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
1261QI0500XInfusion Therapy Clinic/Center
2261QM2500XMedical Specialty Clinic/Center

General Provider Information

NPI Number : 1821148404
Entity Type Code : Organization
Provider Name (Legal Business Name) : WOODSIDE MEDICAL GROUP, INC.
Provider Business Mailing Address
First Line : 475 LEXINGTON AVE
Second Line :
City : MANSFIELD
State : OH
Zip : 44907-1501
Country : US
Telephone Number : 419-756-2003
Fax Number : 419-756-3637
Provider Business Practice Location Address
First Line : 475 LEXINGTON AVE
Second Line :
City : MANSFIELD
State : OH
Zip : 44907-1501
Country : US
Telephone Number : 419-756-2003
Fax Number : 419-756-3637
Authorized Official
Title or Position : PRES
Name : DR. ROBERT EDWIN EXTEN JR.
Credential : MD
Telephone Number : 419-756-2003
Provider Enumeration Date : 01/12/2007
Last Update Date : 10/04/2011

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Directions to “WOODSIDE MEDICAL GROUP, INC. ” Practice Location

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