Basic Information
| Provider Information | |||||||||
| NPI: | 1003809088 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOMBASH | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | CARRINGTON | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GOMBASH | ||||||||
| OtherFirstName: | ANDREW | ||||||||
| OtherMiddleName: | C. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1049 WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | CHILLICOTHE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456011104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7407734366 | ||||||||
| FaxNumber: | 7407757855 | ||||||||
| Practice Location | |||||||||
| Address1: | 1049 WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | CHILLICOTHE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456011104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7407734366 | ||||||||
| FaxNumber: | 7407757855 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2005 | ||||||||
| LastUpdateDate: | 10/07/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 34004365G | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0109967 | 01 | UNITED HEALTHCARE | OTHER | 311155352 | 01 | OH | MEDIGOLD | OTHER | 311155352 | 01 | CIGNA | OTHER | 000000260293 | 01 | OH | ANTHEM | OTHER | 311155352 | 01 | EV BENEFITS | OTHER | 311155352 | 01 | EMERALD HEALTH | OTHER | 311155352 | 01 | GREAT WEST | OTHER | 311155352 | 01 | AETNA | OTHER | 311155352 | 01 | CENTRAL BENEFITS | OTHER | 311155352001 | 01 | TRICARE | OTHER | 0146765 | 05 | OH | MEDICAID | 311155352 | 01 | NATIONWIDE INS. | OTHER | 311155352 | 01 | PPO NEXT | OTHER | 311155352 | 01 | OHIO HEALTH CHOICE | OTHER |