Healthcare Provider Details

I. General information

NPI: 1720342397
Provider Name (Legal Business Name): EXCEL CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2012
Last Update Date: 06/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1480 GRANDVIEW AVE
COLUMBUS OH
43212
US

IV. Provider business mailing address

5340 GORDON WAY
DUBLIN OH
43017
US

V. Phone/Fax

Practice location:
  • Phone: 614-486-9461
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35075884
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN-198389
License Number StateOH

VIII. Authorized Official

Name: MAZHAR HUSSAIN
Title or Position: OWNER
Credential: M.D
Phone: 614-203-0281