Provider Demographics
NPI:1013017417
Name:MID OHIO RENAL DISEASE AND HYPERTENSION SPECIALIST, INC.
Entity Type:Organization
Organization Name:MID OHIO RENAL DISEASE AND HYPERTENSION SPECIALIST, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-287-6300
Mailing Address - Street 1:P.O. BOX 711996
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45271-1996
Mailing Address - Country:US
Mailing Address - Phone:727-287-6300
Mailing Address - Fax:727-287-6306
Practice Address - Street 1:777 WEST STATE STREET
Practice Address - Street 2:SUITE 502
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43222
Practice Address - Country:US
Practice Address - Phone:614-228-4018
Practice Address - Fax:614-228-4237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2389982Medicaid
OH2389982Medicaid