Basic Information
| Provider Information | |||||||||
| NPI: | 1447280151 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PROK | ||||||||
| FirstName: | CHRISTINE | ||||||||
| MiddleName: | M | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8691 FILIZ LN | ||||||||
| Address2: | |||||||||
| City: | POWELL | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430658025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403605728 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6520 WEST CAMPUS OVAL | ||||||||
| Address2: | CENTRAL OHIO SURGICAL INSTITUTE | ||||||||
| City: | NEW ALBANY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144132233 | ||||||||
| FaxNumber: | 6144132234 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | RN287773 | OH | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | NA05478 | OH | N | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 2211421 | 05 | OH | MEDICAID |