Basic Information
| Provider Information | |||||||||
| NPI: | 1265624696 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL OHIO UROLOGY SURGERY CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 PLAZA PROPERTIES BLVD | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432191531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6149444800 | ||||||||
| FaxNumber: | 6149444750 | ||||||||
| Practice Location | |||||||||
| Address1: | 3100 PLAZA PROPERTIES BOULEVARD | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147511010 | ||||||||
| FaxNumber: | 6147514692 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2007 | ||||||||
| LastUpdateDate: | 03/31/2011 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 6149444820 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | M.B.A. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 0843AS | OH | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 2863325 | 01 | OH | MEDICARE ID NUMBER | OTHER | 36C0001231 | 01 | OH | MEDICARE CERTIFICATION NUMBER | OTHER |