Basic Information
| Provider Information | |||||||||
| NPI: | 1336484294 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORACLE PAIN CLINIC, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 121 W 6TH AVE | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 431302587 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7406875164 | ||||||||
| FaxNumber: | 7406541417 | ||||||||
| Practice Location | |||||||||
| Address1: | 4872 CEMETERY RD | ||||||||
| Address2: | |||||||||
| City: | HILLIARD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430261105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6148761618 | ||||||||
| FaxNumber: | 6148761969 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2012 | ||||||||
| LastUpdateDate: | 07/18/2013 | ||||||||
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| AuthorizedOfficialLastName: | ESSANDOH | ||||||||
| AuthorizedOfficialFirstName: | SAMUEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6148761618 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35095632 | OH | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RH0002X | 35095632 | OH | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine | 208VP0000X | 35095632 | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0079001 | 05 | OH | MEDICAID |