1013970565 NPI number — BENITA M PETRI PICKSTONE MD

Table of content: BENITA M PETRI PICKSTONE MD (NPI 1013970565)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013970565 NPI number — BENITA M PETRI PICKSTONE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETRI PICKSTONE
Provider First Name:
BENITA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PETRI
Provider Other First Name:
BENITA
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1013970565
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/23/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
700 ACKERMAN RD STE 2120
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43202-1559
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
614-293-2614
Provider Business Mailing Address Fax Number:
614-293-7001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
920 N HAMILTON RD
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
GAHANNA
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43230-1757
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-293-2614
Provider Business Practice Location Address Fax Number:
614-293-7001
Provider Enumeration Date:
04/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  35072471 , 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: 2072859 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com