Basic Information
| Provider Information | |||||||||
| NPI: | 1245309731 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OHIO GASTROENTEOLOGY GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3400 OLENTANGY RIVER RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432021523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147545500 | ||||||||
| FaxNumber: | 6144579519 | ||||||||
| Practice Location | |||||||||
| Address1: | 85 MCNAUGHTEN RD | ||||||||
| Address2: | STE 320 | ||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432132174 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147545500 | ||||||||
| FaxNumber: | 6147545501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2006 | ||||||||
| LastUpdateDate: | 08/15/2014 | ||||||||
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| AuthorizedOfficialLastName: | EDGIN | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | LAB DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6147545500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 0206235 | 05 | OH | MEDICAID |