=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821774662
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHYSICAL MEDICINE MUSCULOSKELETAL AND NEURODIAGNOSTICS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2023
-----------------------------------------------------
Last Update Date | 06/26/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1210 GEMINI PLACE SUITE 200
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43240-6110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-324-8177
-----------------------------------------------------
Fax | 614-310-7421
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1210 GEMINI PLACE SUITE 200
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43240-6110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-324-8177
-----------------------------------------------------
Fax | 614-310-7421
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPERATIONS
-----------------------------------------------------
Name | SHARON NELSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 614-324-8162
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------