Provider Demographics
NPI:1174867568
Name:PODACH, RYAN JACOB
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:JACOB
Last Name:PODACH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 26
Mailing Address - Street 2:
Mailing Address - City:BLOOMDALE
Mailing Address - State:OH
Mailing Address - Zip Code:44817-0026
Mailing Address - Country:US
Mailing Address - Phone:419-619-1375
Mailing Address - Fax:
Practice Address - Street 1:212 N MAPLE ST
Practice Address - Street 2:
Practice Address - City:BLOOMDALE
Practice Address - State:OH
Practice Address - Zip Code:44817-0026
Practice Address - Country:US
Practice Address - Phone:419-619-1375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide