Basic Information
| Provider Information | |||||||||
| NPI: | 1124591458 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CREACHBAUM | ||||||||
| FirstName: | MARKUS | ||||||||
| MiddleName: | JOHN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 ACKERMAN RD STE 570 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432021579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142939450 | ||||||||
| FaxNumber: | 6142939451 | ||||||||
| Practice Location | |||||||||
| Address1: | 410 W 10TH AVE | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432101240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6146855695 | ||||||||
| FaxNumber: | 6142934726 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2019 | ||||||||
| LastUpdateDate: | 03/18/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 50.005851RX | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0336991 | 05 | OH | MEDICAID |