1396769980 NPI number — COLONIAL CITY INTERNAL MEDICINE, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396769980 NPI number — COLONIAL CITY INTERNAL MEDICINE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COLONIAL CITY INTERNAL MEDICINE, INC.
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:
Provider Other Organization Name Type Code:
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:
1396769980
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1124
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNT VERNON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43050-8124
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
740-397-2975
Provider Business Mailing Address Fax Number:
740-397-3870

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1661 VENTURE DR
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
MOUNT VERNON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43050-8928
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-397-2915
Provider Business Practice Location Address Fax Number:
740-397-3870
Provider Enumeration Date:
07/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CARROLL
Authorized Official First Name:
FREDEROCL
Authorized Official Middle Name:
CHARLES
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
740-397-2915

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  80624 , 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)





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