Provider Demographics
NPI:1558045401
Name:OLIVER, RASEAN
Entity Type:Individual
Prefix:
First Name:RASEAN
Middle Name:
Last Name:OLIVER
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 1:431 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-4004
Mailing Address - Country:US
Mailing Address - Phone:614-885-5020
Mailing Address - Fax:
Practice Address - Street 1:431 E BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-4004
Practice Address - Country:US
Practice Address - Phone:614-885-5020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHTK142529171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty