Provider Demographics
NPI:1346590445
Name:CAPITAL CITY NEUROSURGERY LLC
Entity Type:Organization
Organization Name:CAPITAL CITY NEUROSURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:JIYONG
Authorized Official - Last Name:KIEHM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:614-300-1105
Mailing Address - Street 1:3600 OLENTANGY RIVER RD
Mailing Address - Street 2:BLDG 480
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214-3437
Mailing Address - Country:US
Mailing Address - Phone:614-300-1105
Mailing Address - Fax:614-678-8851
Practice Address - Street 1:3600 OLENTANGY RIVER RD
Practice Address - Street 2:BLDG 480
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-3437
Practice Address - Country:US
Practice Address - Phone:614-300-1105
Practice Address - Fax:614-678-8851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-16
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-080525207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2647112Medicaid
I29328Medicare UPIN