Basic Information
| Provider Information | |||||||||
| NPI: | 1790875656 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLUMBUS ONCOLOGY ASSOCIATES INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | COLUMBUS ONCOLOGY & HEMATOLOGY ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 810 JASONWAY AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432144359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144423130 | ||||||||
| FaxNumber: | 6144423150 | ||||||||
| Practice Location | |||||||||
| Address1: | 810 JASONWAY AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432144359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144423130 | ||||||||
| FaxNumber: | 6144423150 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2006 | ||||||||
| LastUpdateDate: | 06/14/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KOURLAS | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN/OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6144423130 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 06/14/2021 | ||||||||
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 | CM3784 | 01 | OH | RAILROAD MEDICARE | OTHER | 0676648 | 05 | OH | MEDICAID |