Provider Demographics
NPI:1760489413
Name:WYCHOCK, STEPHEN GERALD (PT)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:GERALD
Last Name:WYCHOCK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004-3262
Mailing Address - Country:US
Mailing Address - Phone:440-964-2035
Mailing Address - Fax:440-964-0699
Practice Address - Street 1:607 LAKE AVE
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-3262
Practice Address - Country:US
Practice Address - Phone:440-964-2035
Practice Address - Fax:440-964-0699
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2007-10-04
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-05-02
Provider Licenses
StateLicense IDTaxonomies
OHPT-6573225100000X, 2251E1200X, 2251G0304X, 2251H1200X, 2251N0400X, 2251P0200X, 2251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251E1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistErgonomics
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
No2251H1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHand
No2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP-12042976OtherMULTIPLAN
OH2160561OtherFIRST HEALTH
OH2361699Medicaid
PA233508OtherHEALTH AMERICA HEALTH ASS
PAWY756076OtherHIGHMARK BC/BS
OH000000320301OtherANTHEM BC/BS GROUP#
OH000000320302OtherANTHEM BC/BS IND#
OH200346640-00OtherWORKERS' COMP GROUP#
OH2160561OtherFIRST HEALTH
OH2361699Medicaid
OH200346640-00OtherWORKERS' COMP GROUP#
PAWY756076OtherHIGHMARK BC/BS
PA233508OtherHEALTH AMERICA HEALTH ASS
OHWY4129561Medicare ID - Type UnspecifiedINDIVIDUAL PROVIDER #