Provider Demographics
NPI:1730213950
Name:WESTERVILLE PHYSICIAN INC.
Entity type:Organization
Organization Name:WESTERVILLE PHYSICIAN INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INTERIM FINANCE SUPERVISOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:K
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-546-4232
Mailing Address - Street 1:2150 AGLER RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43224-4523
Mailing Address - Country:US
Mailing Address - Phone:614-416-4325
Mailing Address - Fax:614-546-4243
Practice Address - Street 1:2150 AGLER RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43224-4523
Practice Address - Country:US
Practice Address - Phone:614-416-4325
Practice Address - Fax:614-546-4243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0113230OtherOTHER
OH0113230OtherOTHER
OH361889Medicare PIN