Basic Information
Provider Information | |||||||||
NPI: | 1568789089 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NAUTILUS HEALTH CARE GROUP PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 530968 | ||||||||
Address2: |   | ||||||||
City: | ST PETERSBURG | ||||||||
State: | FL | ||||||||
PostalCode: | 337470968 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7278232188 | ||||||||
FaxNumber: | 7278280723 | ||||||||
Practice Location | |||||||||
Address1: | 50 W BROAD ST | ||||||||
Address2: | STE 1800 | ||||||||
City: | COLUMBUS | ||||||||
State: | OH | ||||||||
PostalCode: | 432153301 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7278675480 | ||||||||
FaxNumber: | 7278675470 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/23/2010 | ||||||||
LastUpdateDate: | 04/23/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MORRISON | ||||||||
AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER / PROVIDER | ||||||||
AuthorizedOfficialTelephone: | 7278685480 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | NAUTILUS HEALTH CARE GROUP PA | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WW0000X | 35.094063 | OH | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Wound Care | 207NS0135X | 35.094063 | OH | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | Procedural Dermatology | 2083P0011X | 35.094063 | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Preventive Medicine | Undersea and Hyperbaric Medicine |
No ID Information.