Healthcare Provider Details

I. General information

NPI: 1205909561
Provider Name (Legal Business Name): GRANTRIVERSIDE MEDICAL CARE FOUNDATION, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 07/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3545 OLENTANGY RIVER RD STE 501
COLUMBUS OH
43214-3907
US

IV. Provider business mailing address

5350 FRANTZ RD
DUBLIN OH
43016-4259
US

V. Phone/Fax

Practice location:
  • Phone: 614-566-2714
  • Fax: 614-566-2712
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: MARK WUESTEWALD
Title or Position: DIRECTOR
Credential:
Phone: 614-566-5643