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NPI Code Detail

MEDICARE: COLUMBUS SOUTHERN MEDICAL GROUP LLC

MEDICARE: COLUMBUS SOUTHERN MEDICAL GROUP LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1261Q00000XClinic/Center

General Provider Information

NPI Number : 1174709422
Entity Type Code : Organization
Provider Name (Legal Business Name) : COLUMBUS SOUTHERN MEDICAL GROUP LLC
Provider Business Mailing Address
First Line : 2912 S HIGH ST
Second Line :
City : COLUMBUS
State : OH
Zip : 43207-3616
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 2912 S HIGH ST
Second Line :
City : COLUMBUS
State : OH
Zip : 43207-3616
Country : US
Telephone Number : 614-497-3400
Fax Number :
Authorized Official
Title or Position : MEDICAL DIRECTOR
Name : KEVIN LAKE
Credential :
Telephone Number : 614-497-3400
Provider Enumeration Date : 01/17/2008
Last Update Date : 01/17/2008

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Directions to “COLUMBUS SOUTHERN MEDICAL GROUP LLC ” Practice Location

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