Healthcare Provider Details

I. General information

NPI: 1174722748
Provider Name (Legal Business Name): QINGGUO SHANG O.M.D., LIC. AC.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2007
Last Update Date: 10/20/2020
Certification Date: 10/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1395 E DUBLIN GRANVILLE RD SUITE 418
COLUMBUS OH
43229-3313
US

IV. Provider business mailing address

3555 MARK TWAIN CT
HILLIARD OH
43026-5729
US

V. Phone/Fax

Practice location:
  • Phone: 614-378-1293
  • Fax:
Mailing address:
  • Phone: 614-378-1293
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number65.000133
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: