Healthcare Provider Details

I. General information

NPI: 1033168802
Provider Name (Legal Business Name): MICHAEL CHI GONG MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 07/10/2025
Certification Date: 07/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W 10TH AVE
COLUMBUS OH
43210-1280
US

IV. Provider business mailing address

700 ACKERMAN RD STE 2120
COLUMBUS OH
43202-1559
US

V. Phone/Fax

Practice location:
  • Phone: 614-685-4263
  • Fax: 614-685-4768
Mailing address:
  • Phone: 614-685-4263
  • Fax: 614-293-3565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number35076686
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: