Basic Information
| Provider Information | |||||||||
| NPI: | 1083934590 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLUMBUS ORTHOPAEDIC GROUP INC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | THE CARDINAL ORTHOPAEDIC INSTITUTE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 170 TAYLOR STATION RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432134441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6145457900 | ||||||||
| FaxNumber: | 6145457901 | ||||||||
| Practice Location | |||||||||
| Address1: | 568 S CLEVELAND AVE | ||||||||
| Address2: | SUITE F | ||||||||
| City: | WESTERVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430818959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6148999966 | ||||||||
| FaxNumber: | 6148992744 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2010 | ||||||||
| LastUpdateDate: | 12/15/2010 | ||||||||
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| AuthorizedOfficialLastName: | INGRAM | ||||||||
| AuthorizedOfficialFirstName: | DALE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CRO | ||||||||
| AuthorizedOfficialTelephone: | 6145457900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | OH | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 2514292 | 05 | OH | MEDICAID |