Basic Information
| Provider Information | |||||||||
| NPI: | 1578747614 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GYNECOLOGIC ONCOLOGY AND PELVIC SURGERY ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 745 W STATE ST | ||||||||
| Address2: | SUITE 550A | ||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432221515 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 745 W STATE ST | ||||||||
| Address2: | SUITE 550A | ||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432221515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143836000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2007 | ||||||||
| LastUpdateDate: | 12/27/2007 | ||||||||
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| AuthorizedOfficialLastName: | VACCARELLO | ||||||||
| AuthorizedOfficialFirstName: | LUIS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 6143836000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 2019836 | 05 | OH | MEDICAID |