Provider Demographics
NPI:1447378567
Name:COLUMBUS PHYSICIAN RESOURCES INC
Entity Type:Organization
Organization Name:COLUMBUS PHYSICIAN RESOURCES INC
Other - Org Name:FOURTH AND DIAMOND MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DO
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:RITENOUR
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:419-571-5290
Mailing Address - Street 1:380 CLINE AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44907-1056
Mailing Address - Country:US
Mailing Address - Phone:419-571-5290
Mailing Address - Fax:419-522-0998
Practice Address - Street 1:380 CLINE AVE STE 1
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44907-1056
Practice Address - Country:US
Practice Address - Phone:419-571-5290
Practice Address - Fax:419-522-0998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2075276Medicaid
OH000000122735OtherANTHEM BCBS OF OH
OH9311162Medicare ID - Type Unspecified
G45907Medicare UPIN