MEDICARE: WESTERVILLE PHYSICIAN INC.

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	261QF0400X	Federally Qualified Health Center (FQHC)		OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0113230	OTHER	OH	OTHER

General Provider Information

NPI Number	:	1730213950
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WESTERVILLE PHYSICIAN INC.

Provider Business Mailing Address
First Line	:	2150 AGLER RD
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43224-4523
Country	:	US
Telephone Number	:	614-416-4325
Fax Number	:	614-546-4243

Provider Business Practice Location Address
First Line	:	2150 AGLER RD
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43224-4523
Country	:	US
Telephone Number	:	614-416-4325
Fax Number	:	614-546-4243

Authorized Official
Title or Position	:	INTERIM FINANCE SUPERVISOR
Name	:	MS. SANDY K WILLIS
Credential	:
Telephone Number	:	614-546-4232

Provider Enumeration Date	:	03/16/2007
Last Update Date	:	01/17/2008

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