=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043751357
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OLYMPIC UROGYNECOLOGY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/20/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3009 SMITH RD STE 400
-----------------------------------------------------
City | FAIRLAWN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44333-2670
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-953-3414
-----------------------------------------------------
Fax | 877-753-3179
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3009 SMITH RD STE 400
-----------------------------------------------------
City | FAIRLAWN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44333-2670
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-953-3414
-----------------------------------------------------
Fax | 877-753-3179
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | COSTAS A APOSTOLIS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 330-953-3414
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207VG0400X
-----------------------------------------------------
Taxonomy Name | Gynecology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207VF0040X
-----------------------------------------------------
Taxonomy Name | Urogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
-----------------------------------------------------
License Number | 35099119
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------