Healthcare Provider Details

I. General information

NPI: 1407233364
Provider Name (Legal Business Name): BEN SEAGREN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2015
Last Update Date: 05/10/2020
Certification Date: 05/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1160 W BROAD ST
COLUMBUS OH
43222-1352
US

IV. Provider business mailing address

1160 W BROAD ST
COLUMBUS OH
43222-1352
US

V. Phone/Fax

Practice location:
  • Phone: 614-274-1455
  • Fax: 614-274-1433
Mailing address:
  • Phone: 614-274-1455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number35.136885
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35.136885
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: