Provider Demographics
NPI:1558436782
Name:NORTHWEST COLUMBUS UROLOGY, INC.
Entity Type:Organization
Organization Name:NORTHWEST COLUMBUS UROLOGY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:S
Authorized Official - Last Name:KNUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-644-5240
Mailing Address - Street 1:498 LONDON AVE
Mailing Address - Street 2:SUITE H
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040-5512
Mailing Address - Country:US
Mailing Address - Phone:937-644-5240
Mailing Address - Fax:937-644-3754
Practice Address - Street 1:498 LONDON AVE
Practice Address - Street 2:SUITE H
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040-5512
Practice Address - Country:US
Practice Address - Phone:937-644-5240
Practice Address - Fax:937-644-3754
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35055629174400000X
OH35063160174400000X
OH35069365174400000X
OH35069608174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5195371OtherAETNA
OH0885127Medicaid
CL2354OtherRR MEDICARE
OHCO9252271Medicare PIN
OHCO9252274Medicare PIN
OH0885127Medicaid