Provider Demographics
NPI:1649386194
Name:WESTERVILLE INTERNAL MEDICINE LLC
Entity Type:Organization
Organization Name:WESTERVILLE INTERNAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GWEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:614-891-8080
Mailing Address - Street 1:484 COUNTY LINE RD W
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43082-7080
Mailing Address - Country:US
Mailing Address - Phone:614-891-8080
Mailing Address - Fax:
Practice Address - Street 1:484 COUNTY LINE RD W
Practice Address - Street 2:SUITE 200
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43082-7080
Practice Address - Country:US
Practice Address - Phone:614-891-8080
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WESTERVILLE INTERNAL MEDICINE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-21
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2445189Medicaid
9339581Medicare PIN