MEDICARE: MOUNT CARMEL HEALTH PROVIDERS III, 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

General Provider Information

NPI Number	:	1710297288
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOUNT CARMEL HEALTH PROVIDERS III, LLC

Provider Business Mailing Address
First Line	:	6150 EAST BROAD STREET
Second Line	:	2ND FLOOR WH 233
City	:	COLUMBUS
State	:	OH
Zip	:	43213-1574
Country	:	US
Telephone Number	:	614-546-4400
Fax Number	:	614-546-4441

Provider Business Practice Location Address
First Line	:	3480 REFUGEE ROAD
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43232-4814
Country	:	US
Telephone Number	:	614-235-4039
Fax Number	:	614-235-4021

Authorized Official
Title or Position	:	COORDINATOR
Name	:	LISA RICHARDSON
Credential	:
Telephone Number	:	614-546-4969

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

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