=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508175449
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEE MICHAEL HLAD DPM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2010
-----------------------------------------------------
Last Update Date | 05/11/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1045 BEECHER XING N STE A
-----------------------------------------------------
City | GAHANNA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43230-4573
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-304-0019
-----------------------------------------------------
Fax | 614-304-0023
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1045 BEECHER XING N SUITE A
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43230-4573
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-478-2111
-----------------------------------------------------
Fax | 614-304-0022
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | 36003610
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 36003610
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------