Basic Information
| Provider Information | |||||||||
| NPI: | 1073907309 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL OHIO UROLOGY GROUP, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 701 TECH CENTER DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | GAHANNA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432301987 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143962684 | ||||||||
| FaxNumber: | 6143962480 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 TECH CENTER DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | GAHANNA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432301987 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143962684 | ||||||||
| FaxNumber: | 6143962480 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2015 | ||||||||
| LastUpdateDate: | 01/25/2019 | ||||||||
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| AuthorizedOfficialLastName: | GIACOMELLI | ||||||||
| AuthorizedOfficialFirstName: | NICOLE | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 6143962635 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 1495470 | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 2660820 | 05 | OH | MEDICAID |