Provider Demographics
NPI:1770972143
Name:AETNA PROVIDER SERVICE
Entity type:Organization
Organization Name:AETNA PROVIDER SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INDEPENDENT PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:MEMUNATU
Authorized Official - Middle Name:
Authorized Official - Last Name:SHERIFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-946-5475
Mailing Address - Street 1:8514 ARLEN DR
Mailing Address - Street 2:
Mailing Address - City:BLACKLICK
Mailing Address - State:OH
Mailing Address - Zip Code:43004-8155
Mailing Address - Country:US
Mailing Address - Phone:614-946-5475
Mailing Address - Fax:
Practice Address - Street 1:8514 ARLEN DRIVE
Practice Address - Street 2:
Practice Address - City:BLACKLICK
Practice Address - State:OH
Practice Address - Zip Code:43004
Practice Address - Country:US
Practice Address - Phone:614-946-5475
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-22
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2366658253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2366658Medicaid