Basic Information
| Provider Information | |||||||||
| NPI: | 1568761864 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NI | ||||||||
| FirstName: | MICKEY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 ACKERMAN RD | ||||||||
| Address2: | SUITE 570 | ||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432021559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142938054 | ||||||||
| FaxNumber: | 6142936631 | ||||||||
| Practice Location | |||||||||
| Address1: | 2050 KENNY RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432213502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142938054 | ||||||||
| FaxNumber: | 6142934890 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2011 | ||||||||
| LastUpdateDate: | 02/11/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | CA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | 35123314 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.