Basic Information
| Provider Information | |||||||||
| NPI: | 1265658918 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SUN | ||||||||
| FirstName: | SHAOLI | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 ACKERMAN RD STE 2120 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432021559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142935905 | ||||||||
| FaxNumber: | 6142934715 | ||||||||
| Practice Location | |||||||||
| Address1: | 410 W 10TH AVE | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432101240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142935905 | ||||||||
| FaxNumber: | 6142934715 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2007 | ||||||||
| LastUpdateDate: | 03/19/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 33101 | SC | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | 35137454 | OH | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 0395267 | 05 | OH | MEDICAID |