=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639318132
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PATRICIA E. WONGSAM M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2009
-----------------------------------------------------
Last Update Date | 02/07/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1747 BRYDEN RD
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43205-2221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-581-2115
-----------------------------------------------------
Fax | 614-261-1700
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 529
-----------------------------------------------------
City | LEWIS CENTER
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43035-0529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-581-2115
-----------------------------------------------------
Fax | 614-261-1700
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | 35043185
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------