Provider Demographics
NPI:1326399932
Name:GRANT/RIVERSIDE MEDICAL CARE FOUNDATION, INC
Entity Type:Organization
Organization Name:GRANT/RIVERSIDE MEDICAL CARE FOUNDATION, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OHMSF CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:WILKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-544-6382
Mailing Address - Street 1:5350 FRANTZ RD.
Mailing Address - Street 2:STE 250
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43016
Mailing Address - Country:US
Mailing Address - Phone:614-544-6382
Mailing Address - Fax:
Practice Address - Street 1:111 S. GRANT AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215
Practice Address - Country:US
Practice Address - Phone:614-566-9160
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-21
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH13750282N00000X
OHCOA13750NP363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty
No282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH13750-NPOtherCERTIFICATE OF AUTHORITY