=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568904795
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OHIO STATE UNIVERSITY WEXNER MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2016
-----------------------------------------------------
Last Update Date | 11/04/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1670 UPHAM DR
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43210-1250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-685-9056
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1670 UPHAM DR
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43210-1250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHIATRIC EMERGENCY SERVICES CLIN
-----------------------------------------------------
Name | LAUREN CHISHOLM
-----------------------------------------------------
Credential | LISW-S
-----------------------------------------------------
Telephone | 614-685-9056
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 283Q00000X
-----------------------------------------------------
Taxonomy Name | Psychiatric Hospital
-----------------------------------------------------
License Number | I.1500390-SUPV
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------