Basic Information
| Provider Information | |||||||||
| NPI: | 1689919599 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OSU GENERAL INTERNAL MEDICINE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 ACKERMAN RD STE 2120 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432021559 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2050 KENNY RD | ||||||||
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| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432213502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142938054 | ||||||||
| FaxNumber: | 6142934890 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2012 | ||||||||
| LastUpdateDate: | 02/28/2022 | ||||||||
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| AuthorizedOfficialLastName: | MOELLER | ||||||||
| AuthorizedOfficialFirstName: | ANN | ||||||||
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| AuthorizedOfficialTitleorPosition: | ASSOCIATE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6142935288 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 111N00000X | N | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor | 171100000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Acupuncturist | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207QS0010X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 225700000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0076572 | 05 | OH | MEDICAID | H176890 | 01 | OH | MEDICARE | OTHER |