MEDICARE: MR. EVERISTUS BASIL ITIE

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	251E00000X	Home Health Agency
2	251J00000X	Nursing Care Agency
3	343900000X	Non-emergency Medical Transport (VAN)

General Provider Information

NPI Number	:	1093883712
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. EVERISTUS BASIL ITIE

Provider Business Mailing Address
First Line	:	788 BUSCH CT
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43229-1704
Country	:	US
Telephone Number	:	614-848-3900
Fax Number	:	614-848-3901

Provider Business Practice Location Address
First Line	:	788 BUSCH CT
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43229-1704
Country	:	US
Telephone Number	:	614-848-3900
Fax Number	:	614-848-3901

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/01/2006
Last Update Date	:	12/20/2011

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