Basic Information
| Provider Information | |||||||||
| NPI: | 1063514107 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OHIO SURGERY CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 930 BETHEL RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432141906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144510500 | ||||||||
| FaxNumber: | 6144512844 | ||||||||
| Practice Location | |||||||||
| Address1: | 930 BETHEL RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432141906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144510500 | ||||||||
| FaxNumber: | 6144512844 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2006 | ||||||||
| LastUpdateDate: | 12/04/2012 | ||||||||
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| AuthorizedOfficialLastName: | MARTYN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CHARIMAN OF THE BOARD | ||||||||
| AuthorizedOfficialTelephone: | 6144510500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 386 | OH | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | OH2070646 | 05 | OH | MEDICAID |