Basic Information
| Provider Information | |||||||||
| NPI: | 1982818381 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MID-OHIO MEDICAL SPECIALISTS, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 E MAIN ST STE 110 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432155369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142415500 | ||||||||
| FaxNumber: | 6142219522 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 E MAIN ST STE 110 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432155369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142415500 | ||||||||
| FaxNumber: | 6142219522 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2007 | ||||||||
| LastUpdateDate: | 05/09/2018 | ||||||||
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| AuthorizedOfficialLastName: | SHAREEF | ||||||||
| AuthorizedOfficialFirstName: | NAYYAR | ||||||||
| AuthorizedOfficialMiddleName: | FATIMA | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE-PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6142415500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35067934 | OH | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207RC0200X | 35047929 | OH | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | 35047929 | OH | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207R00000X | 35047929 | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0764098 | 05 | OH | MEDICAID | 0170550 | 05 | OH | MEDICAID |