Provider Demographics
NPI:1356059372
Name:NATIONAL CHURCH RESIDENCES MEDICAL HOME
Entity type:Organization
Organization Name:NATIONAL CHURCH RESIDENCES MEDICAL HOME
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DIMICKELE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-451-2151
Mailing Address - Street 1:2245 N BANK DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43220-5422
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2245 N BANK DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43220-5422
Practice Address - Country:US
Practice Address - Phone:614-457-6950
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NATIONAL CHURCH RESIDENCES MEDICAL HOME
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-11-08
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative MedicineGroup - Single Specialty