Provider Demographics
NPI:1790837789
Name:PHYSICIAN'S PRACTICE ORGANIZATION
Entity Type:Organization
Organization Name:PHYSICIAN'S PRACTICE ORGANIZATION
Other - Org Name:COLUMBUS GYNECOLOGY AND ADULT MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-372-8426
Mailing Address - Street 1:2326 18TH ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47201-5359
Mailing Address - Country:US
Mailing Address - Phone:812-372-8426
Mailing Address - Fax:812-372-8301
Practice Address - Street 1:2326 18TH ST
Practice Address - Street 2:SUITE 210
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-5359
Practice Address - Country:US
Practice Address - Phone:812-372-8426
Practice Address - Fax:812-372-8301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01037446174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INCF9669OtherMEDICARE RAILROAD