Healthcare Provider Details

I. General information

NPI: 1861449407
Provider Name (Legal Business Name): OSU OTOLARYNGOLOGY HEAD AND NECK SURGERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 04/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 OLENTANGY RIVER RD SUITE 4000
COLUMBUS OH
43212-3153
US

IV. Provider business mailing address

915 OLENTANGY RIVER RD SUITE 4000
COLUMBUS OH
43212-3153
US

V. Phone/Fax

Practice location:
  • Phone: 614-366-3687
  • Fax: 614-293-3193
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: MARK INMAN
Title or Position: BUSINESS MANAGER
Credential:
Phone: 614-293-3470