Healthcare Provider Details

I. General information

NPI: 1306238621
Provider Name (Legal Business Name): MICHAEL PIERCE EBAUGH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2015
Last Update Date: 03/18/2020
Certification Date: 03/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 W BROAD ST DOCTORS HOSPITAL
COLUMBUS OH
43228-1607
US

IV. Provider business mailing address

2920 W WALLCRAFT AVE
TAMPA FL
33611-1651
US

V. Phone/Fax

Practice location:
  • Phone: 614-544-1000
  • Fax: 614-544-1751
Mailing address:
  • Phone: 813-505-7610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License NumberS4133
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: