Basic Information
| Provider Information | |||||||||
| NPI: | 1700882818 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOURLAS | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 810 JASONWAY AVE | ||||||||
| Address2: | STE A | ||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432144359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144423130 | ||||||||
| FaxNumber: | 6144423145 | ||||||||
| Practice Location | |||||||||
| Address1: | 810 JASONWAY AVE | ||||||||
| Address2: | STE A | ||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432144359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144423130 | ||||||||
| FaxNumber: | 6144423145 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2005 | ||||||||
| LastUpdateDate: | 06/14/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 35071006 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 000000192857 | 01 | OH | ANTHEM | OTHER | 900003674 | 01 | OH | RAILROAD MEDICARE | OTHER | 3600501 | 01 | OH | UHC | OTHER | 2218577 | 05 | OH | MEDICAID | 78704 | 01 | OH | NATIONWIDE | OTHER |