MEDICARE: MED COLUMBUS, 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	207Q00000X	Family Medicine Physician	35053771	OH

General Provider Information

NPI Number	:	1710214168
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MED COLUMBUS, LLC

Provider Business Mailing Address
First Line	:	1020 DENNISON AVE
Second Line	:	SUITE 200
City	:	COLUMBUS
State	:	OH
Zip	:	43201-3497
Country	:	US
Telephone Number	:	614-564-9067
Fax Number	:	614-564-9167

Provider Business Practice Location Address
First Line	:	1020 DENNISON AVE
Second Line	:	SUITE #200
City	:	COLUMBUS
State	:	OH
Zip	:	43201-3497
Country	:	US
Telephone Number	:	614-564-9067
Fax Number	:	614-564-9167

Authorized Official
Title or Position	:	PRESIDENT
Name	:	KAREN A CLEMENCY
Credential	:	M.D.
Telephone Number	:	614-564-9067

Provider Enumeration Date	:	11/05/2009
Last Update Date	:	09/27/2011

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