Basic Information
Provider Information | |||||||||
NPI: | 1003938051 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WONGCHAOWART | ||||||||
FirstName: | NICHOLAS | ||||||||
MiddleName: | T | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 20452 | ||||||||
Address2: | CORPATH CRED | ||||||||
City: | COLUMBUS | ||||||||
State: | OH | ||||||||
PostalCode: | 432200452 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6144422406 | ||||||||
FaxNumber: | 6144422410 | ||||||||
Practice Location | |||||||||
Address1: | 3535 OLENTANGY RIVER RD | ||||||||
Address2: | RMH PATHOLOGY DEPT | ||||||||
City: | COLUMBUS | ||||||||
State: | OH | ||||||||
PostalCode: | 432143908 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6145664945 | ||||||||
FaxNumber: | 6142631056 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/03/2007 | ||||||||
LastUpdateDate: | 05/16/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 35-087155 | OH | Y |   | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZH0000X | 35087155 | OH | N |   | Allopathic & Osteopathic Physicians | Pathology | Hematology |
ID Information
ID | Type | State | Issuer | Description | POO415775 | 01 | OH | RR MEDICARE | OTHER | 2737971 | 05 | OH |   | MEDICAID |