1073855193 NPI number — BUCKEYE ORAL & MAXILLOFACIAL SURGEY

Table of content: (NPI 1073855193)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073855193 NPI number — BUCKEYE ORAL & MAXILLOFACIAL SURGEY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BUCKEYE ORAL & MAXILLOFACIAL SURGEY
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:
BUCKEYE ORAL & MAXILLOFACIAL SURGERY
Provider Other Organization Name Type Code:
4
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:
1073855193
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/27/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2443
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESTERVILLE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43086-2443
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
614-794-9700
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 POLARIS PARKWAY
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
WESTERVILLE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43082-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-794-9700
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/27/2013

Additional Information

Authorized Official

Authorized Official Last Name:
MCEWAN
Authorized Official First Name:
JACK
Authorized Official Middle Name:
B
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
614-794-9700

Provider Taxonomy Codes

  • Taxonomy code: 261QS0112X , with the licence number:  30022456 , 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: 2711882 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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