Basic Information
| Provider Information | |||||||||
| NPI: | 1639263569 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHYSICIAN'S PRACTICE ORGANIZATION, INC. D/B/A COLUMBUS PEDIATRICS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1120 N MARR RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472015505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123769219 | ||||||||
| FaxNumber: | 8123480297 | ||||||||
| Practice Location | |||||||||
| Address1: | 1120 N MARR RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472015505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123769219 | ||||||||
| FaxNumber: | 8123480297 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 03/25/2011 | ||||||||
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| AuthorizedOfficialLastName: | HYER | ||||||||
| AuthorizedOfficialFirstName: | ROBBIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8123769219 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 100052040 | 05 | IN | MEDICAID |