1720132186 NPI number — MR. BENJAMIN VON HODGE BACHELORS OF PHYSICA

Table of content: MR. BENJAMIN VON HODGE BACHELORS OF PHYSICA (NPI 1720132186)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720132186 NPI number — MR. BENJAMIN VON HODGE BACHELORS OF PHYSICA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HODGE
Provider First Name:
BENJAMIN
Provider Middle Name:
VON
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
BACHELORS OF PHYSICA
Provider Gender Code:
M

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:
1720132186
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5688 BURNTWOOD WAY
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:
43081-6603
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
614-620-3009
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
698 MORRISON ROAD
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:
43213
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-868-1115
Provider Business Practice Location Address Fax Number:
614-863-9338
Provider Enumeration Date:
01/23/2007

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: 225100000X , with the licence number:  PT010431 , 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: 2698371 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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