Provider Demographics
NPI:1093883712
Name:ITIE, EVERISTUS BASIL
Entity Type:Individual
Prefix:MR
First Name:EVERISTUS
Middle Name:BASIL
Last Name:ITIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:788 BUSCH CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43229-1704
Mailing Address - Country:US
Mailing Address - Phone:614-848-3900
Mailing Address - Fax:614-848-3901
Practice Address - Street 1:788 BUSCH CT
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43229-1704
Practice Address - Country:US
Practice Address - Phone:614-848-3900
Practice Address - Fax:614-848-3901
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251J00000XAgenciesNursing Care
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)