=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013008192
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MATERNOHIO CLINICAL ASSOCIATES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2006
-----------------------------------------------------
Last Update Date | 02/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1315 W LANE AVE STE D
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43221-3544
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-457-4827
-----------------------------------------------------
Fax | 614-326-0250
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1700 LAKE SHORE DR STE 350
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43204-4895
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF FINANCIAL OFFICER
-----------------------------------------------------
Name | JIM YERINA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 614-641-4024
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 35083946
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------