MEDICARE: COLUMBUS STATE UNIVERSITY

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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1528363066
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLUMBUS STATE UNIVERSITY

Provider Business Mailing Address
First Line	:	PO BOX 671205
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75267-1205
Country	:	US
Telephone Number	:	866-890-6390
Fax Number	:	469-735-4640

Provider Business Practice Location Address
First Line	:	4225 UNIVERSITY AVE
Second Line	:	TUCKER HALL
City	:	COLUMBUS
State	:	GA
Zip	:	31907-5679
Country	:	US
Telephone Number	:	706-507-8620
Fax Number	:	706-568-2039

Authorized Official
Title or Position	:	DIRECTOR, HEALTH SVC
Name	:	BECKY TEW
Credential	:
Telephone Number	:	706-507-8260

Provider Enumeration Date	:	01/13/2011
Last Update Date	:	01/13/2011

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Practice Location Address:

4225 UNIVERSITY AVE
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31907-5679

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1497084297 — MR. JARED SALVATORE SANDLER ATC
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1770812547 — MR. JULIO CESAR LLANOS JR. ATC
Practice Location Address:

4225 UNIVERSITY AVE , ATTN: JULIO LLANOS - ATHLETICS
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31907-5679

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1205165099 — KATHRYN ANNE CARDINAL ATC
Practice Location Address:

4225 UNIVERSITY AVE , ATTN: ATHLETICS
COLUMBUS, GA
31907-5679

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1285916460 — DR. S LENOIR GILLAM PHD
Practice Location Address:

4225 UNIVERSITY AVE , SCHUSTER CENTER, THIRD FLOOR
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31907-5679

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1144502329 — KATE JEAN ROSSELLO PSYD
Practice Location Address:

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31907-5679

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Practice Fax:

Directions to “COLUMBUS STATE UNIVERSITY ” Practice Location

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