=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740410802
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GREGG JEREMY NIGL PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2009
-----------------------------------------------------
Last Update Date | 12/15/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 420 N JAMES RD MH/BSS
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43219-1834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-388-7095
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3959 SUMMERSTONE DR
-----------------------------------------------------
City | GAHANNA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43230-7379
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-245-4084
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number | PSO16653
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------