1104904614 NPI number — MEDISERV DUXBERRY PHCY INC

Table of content: (NPI 1104904614)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104904614 NPI number — MEDISERV DUXBERRY PHCY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDISERV DUXBERRY PHCY 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:
6
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:
1104904614
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:
2052 CLEVELAND AVE
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:
43211-2216
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2052 CLEVELAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43211-2216
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-294-0426
Provider Business Practice Location Address Fax Number:
614-481-4272
Provider Enumeration Date:
11/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HAMMOND
Authorized Official First Name:
TRACY
Authorized Official Middle Name:
Authorized Official Title or Position:
THIRD PARTY ADMIN
Authorized Official Telephone Number:
614-481-4272

Provider Taxonomy Codes

  • Taxonomy code: 3336C0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 3336C0003X , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 2051872 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3665001 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".




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