Basic Information
| Provider Information | |||||||||
| NPI: | 1295136125 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOUNT CARMEL HEALTH SYSTEM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 EASTON SQUARE PL | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432196289 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343433320 | ||||||||
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| Practice Location | |||||||||
| Address1: | 793 W STATE ST | ||||||||
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| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432221551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142345227 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2014 | ||||||||
| LastUpdateDate: | 09/23/2022 | ||||||||
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| AuthorizedOfficialLastName: | PRIDAY | ||||||||
| AuthorizedOfficialFirstName: | ANDREW | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6145464146 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MOUNT CARMEL HEALTH SYSTEM | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 09/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 36D0953122 | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 6196165 | 05 | OH | MEDICAID |