MEDICARE: OHIO ARMY NATIONAL GUARD

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	251B00000X	Case Management Agency	0900648	OH
2	251S00000X	Community/Behavioral Health Agency	0922648	OH

General Provider Information

NPI Number	:	1598175010
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OHIO ARMY NATIONAL GUARD

Provider Business Mailing Address
First Line	:	3990 E BROAD ST
Second Line	:	DSCC, BUILDING 11, SEC.11
City	:	COLUMBUS
State	:	OH
Zip	:	43213-1152
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3990 E BROAD ST
Second Line	:	DSCC, BUILDING 11, SEC.11
City	:	COLUMBUS
State	:	OH
Zip	:	43213-1152
Country	:	US
Telephone Number	:	614-336-7393
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL THERAPIST/SOCIAL WORKER
Name	:	DAVID ISAAC KIRKER
Credential	:	LISW
Telephone Number	:	614-336-7393

Provider Enumeration Date	:	05/06/2014
Last Update Date	:	05/06/2014

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Directions to “OHIO ARMY NATIONAL GUARD ” Practice Location

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