Healthcare Provider Details

I. General information

NPI: 1710981543
Provider Name (Legal Business Name): GREGORY P AVELLANA PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 01/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 W 5TH AVE
COLUMBUS OH
43212-2495
US

IV. Provider business mailing address

1376 MEADOW RD
COLUMBUS OH
43212-3067
US

V. Phone/Fax

Practice location:
  • Phone: 614-488-6528
  • Fax: 614-488-0226
Mailing address:
  • Phone: 614-485-0112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.004338
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number5107
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: