Healthcare Provider Details

I. General information

NPI: 1740410802
Provider Name (Legal Business Name): GREGG JEREMY NIGL PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2009
Last Update Date: 12/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 N JAMES RD MH/BSS
COLUMBUS OH
43219-1834
US

IV. Provider business mailing address

3959 SUMMERSTONE DR
GAHANNA OH
43230-7379
US

V. Phone/Fax

Practice location:
  • Phone: 614-388-7095
  • Fax:
Mailing address:
  • Phone: 614-245-4084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSO16653
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: