1568497774 NPI number — OHIO STATE PAIN MANAGEMENT CENTER,LLC

Table of content: (NPI 1568497774)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568497774 NPI number — OHIO STATE PAIN MANAGEMENT CENTER,LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OHIO STATE PAIN MANAGEMENT CENTER,LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
COLUMBUS INTERVENTIONAL PAIN CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568497774
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7036 CORPORATE WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAYTON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45459-4237
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-253-6448
Provider Business Mailing Address Fax Number:
937-253-5971

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3400 OLENTANGY RIVER RD
Provider Second Line Business Practice Location Address:
SUITE #100
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43202-1576
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-262-7246
Provider Business Practice Location Address Fax Number:
614-262-4699
Provider Enumeration Date:
07/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MANOCHA
Authorized Official First Name:
SACHIDA
Authorized Official Middle Name:
N
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
614-262-7246

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X , with the licence number:  35-082815 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DF6837 . This is a "RRMEDICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2843258 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000392176 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 612459400 . This is a "FEDERAL WORKERS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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