Basic Information
Provider Information | |||||||||
NPI: | 1538117551 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | OSU SURGERY, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 700 ACKERMAN RD STE 2120 | ||||||||
Address2: |   | ||||||||
City: | COLUMBUS | ||||||||
State: | OH | ||||||||
PostalCode: | 432021559 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6146850010 | ||||||||
FaxNumber: | 6146852883 | ||||||||
Practice Location | |||||||||
Address1: | 410 W 10TH AVE | ||||||||
Address2: |   | ||||||||
City: | COLUMBUS | ||||||||
State: | OH | ||||||||
PostalCode: | 432101240 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6142933230 | ||||||||
FaxNumber: | 6142934030 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/04/2006 | ||||||||
LastUpdateDate: | 01/28/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PAWLIK | ||||||||
AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
AuthorizedOfficialMiddleName: | M. | ||||||||
AuthorizedOfficialTitleorPosition: | DEPARTMENT CHAIR | ||||||||
AuthorizedOfficialTelephone: | 6142938701 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: | 01/28/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 208600000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 0693030 | 05 | OH |   | MEDICAID |