MEDICARE: KJB PROCTOLOGY, LLC

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	208C00000X	Colon & Rectal Surgery Physician	34.009849	OH

General Provider Information

NPI Number	:	1386954899
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KJB PROCTOLOGY, LLC

Provider Business Mailing Address
First Line	:	5580 HILLIARD ROME OFFICE PARK
Second Line	:
City	:	HILLIARD
State	:	OH
Zip	:	43026-7286
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5580 HILLIARD ROME OFFICE PARK
Second Line	:
City	:	HILLIARD
State	:	OH
Zip	:	43026-7286
Country	:	US
Telephone Number	:	614-921-8686
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JESSICA LYNN PRICE
Credential	:	D.O.
Telephone Number	:	614-921-8686

Provider Enumeration Date	:	10/18/2010
Last Update Date	:	10/18/2010

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