Provider Demographics
NPI:1740386424
Name:OHIO CENTER OF COSMETIC & LASER SURGERY
Entity type:Organization
Organization Name:OHIO CENTER OF COSMETIC & LASER SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:T
Authorized Official - Last Name:RYU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-592-3277
Mailing Address - Street 1:PO BOX 2910
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45501
Mailing Address - Country:US
Mailing Address - Phone:937-390-3277
Mailing Address - Fax:937-390-1330
Practice Address - Street 1:921 E SANDUSKY AVE
Practice Address - Street 2:
Practice Address - City:BELLEFONTAINE
Practice Address - State:OH
Practice Address - Zip Code:43311
Practice Address - Country:US
Practice Address - Phone:937-592-3277
Practice Address - Fax:937-592-3753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH311261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
DA3611151Medicare ID - Type Unspecified