Healthcare Provider Details

I. General information

NPI: 1386954899
Provider Name (Legal Business Name): KJB PROCTOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2010
Last Update Date: 10/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5580 HILLIARD ROME OFFICE PARK
HILLIARD OH
43026-7286
US

IV. Provider business mailing address

5580 HILLIARD ROME OFFICE PARK
HILLIARD OH
43026-7286
US

V. Phone/Fax

Practice location:
  • Phone: 614-921-8686
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number34.009849
License Number StateOH

VIII. Authorized Official

Name: JESSICA LYNN PRICE
Title or Position: OWNER
Credential: D.O.
Phone: 614-921-8686