Basic Information
Provider Information | |||||||||
NPI: | 1043278617 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BAZZOLI | ||||||||
FirstName: | JAMES | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | L-3549 | ||||||||
Address2: |   | ||||||||
City: | COLUMBUS | ||||||||
State: | OH | ||||||||
PostalCode: | 432600001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7403837927 | ||||||||
FaxNumber: | 7403837942 | ||||||||
Practice Location | |||||||||
Address1: | 1040 DELAWARE AVE | ||||||||
Address2: |   | ||||||||
City: | MARION | ||||||||
State: | OH | ||||||||
PostalCode: | 433026416 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7403838080 | ||||||||
FaxNumber: | 7403838084 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/03/2006 | ||||||||
LastUpdateDate: | 12/15/2021 | ||||||||
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 | 207V00000X | 35039399B | OH | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | 160017770 | 01 |   | TRAVELERS MEDICARE | OTHER | 2873884400 | 01 | OH | BWC | OTHER | 311098079 | 01 |   | TAXID E | OTHER | 311098079 | 01 |   | TAX ID | OTHER | 000000118145 | 01 | OH | ANTHEM | OTHER | 353077 | 01 |   | SUBMITTER NO | OTHER | 0308161 | 05 | OH |   | MEDICAID | 0700040 | 01 |   | UHC | OTHER | 311098079060 | 01 |   | CIGNA | OTHER | 646799 | 01 |   | AETNA | OTHER |