Provider Demographics
NPI:1043751357
Name:OLYMPIC UROGYNECOLOGY, LLC
Entity Type:Organization
Organization Name:OLYMPIC UROGYNECOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:COSTAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:APOSTOLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-953-3414
Mailing Address - Street 1:3009 SMITH RD STE 400
Mailing Address - Street 2:
Mailing Address - City:FAIRLAWN
Mailing Address - State:OH
Mailing Address - Zip Code:44333-2670
Mailing Address - Country:US
Mailing Address - Phone:330-953-3414
Mailing Address - Fax:877-753-3179
Practice Address - Street 1:3009 SMITH RD STE 400
Practice Address - Street 2:
Practice Address - City:FAIRLAWN
Practice Address - State:OH
Practice Address - Zip Code:44333-2670
Practice Address - Country:US
Practice Address - Phone:330-953-3414
Practice Address - Fax:877-753-3179
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35099119207VF0040X
207VG0400X
OH35-0991192088F0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2088F0040XAllopathic & Osteopathic PhysiciansUrologyFemale Pelvic Medicine and Reconstructive SurgeryGroup - Single Specialty
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyFemale Pelvic Medicine and Reconstructive SurgeryGroup - Single Specialty
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0228002Medicaid