MEDICARE: MID OHIO ORTHOPAEDIC SURGERY & SPORTS MEDICINE INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207X00000X	Orthopaedic Surgery Physician

General Provider Information

NPI Number	:	1023203015
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MID OHIO ORTHOPAEDIC SURGERY & SPORTS MEDICINE INC

Provider Business Mailing Address
First Line	:	51 S SOUDER AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43222-1548
Country	:	US
Telephone Number	:	614-228-2808
Fax Number	:	614-221-0079

Provider Business Practice Location Address
First Line	:	51 S SOUDER AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43222-1548
Country	:	US
Telephone Number	:	614-228-2808
Fax Number	:	614-221-0079

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. STEPHEN N KOLODZIK
Credential	:	MD
Telephone Number	:	614-228-2808

Provider Enumeration Date	:	09/12/2007
Last Update Date	:	11/06/2007

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