=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730238312
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SURGICAL NEUROLOGY OF NORTH CENTRAL OHIO, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 295 GLESSNER AVE
-----------------------------------------------------
City | MANSFIELD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44903-2270
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-522-1100
-----------------------------------------------------
Fax | 419-522-4118
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 295 GLESSNER AVE
-----------------------------------------------------
City | MANSFIELD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44903-2270
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-522-1100
-----------------------------------------------------
Fax | 419-522-4118
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ALBERT L TIMPERMAN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 419-522-1100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 35027380T
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------