Provider Demographics
NPI:1619409109
Name:CENTRAL OHIO UROLOGY GROUP, LLC
Entity Type:Organization
Organization Name:CENTRAL OHIO UROLOGY GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MRS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:GIACOMELLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-396-2635
Mailing Address - Street 1:350 W WILSON BRIDGE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WORTHINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43085-2217
Mailing Address - Country:US
Mailing Address - Phone:614-796-2900
Mailing Address - Fax:614-796-2901
Practice Address - Street 1:350 W WILSON BRIDGE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:WORTHINGTON
Practice Address - State:OH
Practice Address - Zip Code:43085-2217
Practice Address - Country:US
Practice Address - Phone:614-796-2900
Practice Address - Fax:614-796-2901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-03
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2660820Medicaid
OHCE9361931Medicare PIN