Provider Demographics
NPI:1376579755
Name:COLUMBUS SOUTHERN MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:COLUMBUS SOUTHERN MEDICAL GROUP LLC
Other - Org Name:DR GURSAL LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:LAKE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:614-748-2000
Mailing Address - Street 1:2912 S HIGH STREET
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43207
Mailing Address - Country:US
Mailing Address - Phone:614-748-2000
Mailing Address - Fax:614-748-3000
Practice Address - Street 1:2912 S HIGH STREET
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43207
Practice Address - Country:US
Practice Address - Phone:614-748-2000
Practice Address - Fax:614-748-3000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH34005855L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty