Healthcare Provider Details

I. General information

NPI: 1770577694
Provider Name (Legal Business Name): THEODORE H NIEMANN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 05/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

793 W STATE ST MT CARMEL WEST HOSPITAL PATHOLOGY DEPT
COLUMBUS OH
43222-1551
US

IV. Provider business mailing address

PO BOX 20452 COPA-CRED
COLUMBUS OH
43220-0452
US

V. Phone/Fax

Practice location:
  • Phone: 614-234-1300
  • Fax: 614-234-2931
Mailing address:
  • Phone: 614-888-2733
  • Fax: 614-442-2410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License Number35066598
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number35066598
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: