Basic Information
Provider Information | |||||||||
NPI: | 1700100419 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOUTH CENTRAL OHIO ANESTHESIA LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 601 WASHINGTON AVE | ||||||||
Address2: | SUITE 390 | ||||||||
City: | NEWPORT | ||||||||
State: | KY | ||||||||
PostalCode: | 410711986 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8596558554 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 601 STATE ROUTE 664 N | ||||||||
Address2: |   | ||||||||
City: | LOGAN | ||||||||
State: | OH | ||||||||
PostalCode: | 431388541 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7409830397 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/24/2010 | ||||||||
LastUpdateDate: | 06/24/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | VEITH | ||||||||
AuthorizedOfficialFirstName: | JON | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 7409830397 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | CRNA | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | COA.02437-NA | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |   |
ID Information
ID | Type | State | Issuer | Description | 1255303160 | 01 | OH | INDIVIDUAL NPI | OTHER |