Healthcare Provider Details

I. General information

NPI: 1538940929
Provider Name (Legal Business Name): NPMIKE01
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2023
Last Update Date: 11/08/2023
Certification Date: 11/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 S HAMILTON RD STE E
COLUMBUS OH
43227-2414
US

IV. Provider business mailing address

PO BOX 27611
COLUMBUS OH
43227-0611
US

V. Phone/Fax

Practice location:
  • Phone: 855-676-4531
  • Fax: 855-676-4531
Mailing address:
  • Phone: 855-676-4531
  • Fax: 855-676-4531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL A HODGE
Title or Position: OWNER
Credential: APN
Phone: 347-451-2739