1184722126 NPI number — JAMES P. REARDON

Table of content: (NPI 1184722126)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184722126 NPI number — JAMES P. REARDON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JAMES P. REARDON
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 TRAUMATIC STRESS 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:
1184722126
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 BRADENTON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DUBLIN
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43017-7515
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
614-793-1980
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7550 PINGUE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WORTHINGTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43085-1714
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-436-9985
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
REARDON
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
P.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
614-436-9985

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  2564 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TC1900X , with the licence number: 2564 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TF0200X , with the licence number: 2564 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TR0400X , with the licence number: 2564 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0355459 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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