Basic Information
| Provider Information | |||||||||
| NPI: | 1003220187 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL OHIO ENDOSCOPY CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3400 OLENTANGY RIVER RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432021523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147545500 | ||||||||
| FaxNumber: | 6144579519 | ||||||||
| Practice Location | |||||||||
| Address1: | 3400 OLENTANGY RIVER RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432021523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147545500 | ||||||||
| FaxNumber: | 6144579519 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2014 | ||||||||
| LastUpdateDate: | 11/08/2018 | ||||||||
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| AuthorizedOfficialLastName: | JOCHEM | ||||||||
| AuthorizedOfficialFirstName: | VICTOR | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6147545500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | OH | N | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical | 261QE0800X | Y | Ambulatory Health Care Facilities | Clinic/Center | Endoscopy |
ID Information
| ID | Type | State | Issuer | Description | 1101AS | 01 | OH | ODH STATE LICENSE | OTHER |