| National Church Residences Medical Home | |
|
398 S Grant Ave Columbus OH 43215-5549 | |
| (614) 224-2988 | |
| (614) 716-0902 |
| Full Name | National Church Residences Medical Home |
|---|---|
| Speciality | Family Medicine |
| Location | 398 S Grant Ave, Columbus, Ohio |
| Authorized Official Name and Position | Susan Dimickele (PRESIDENT) |
| Authorized Official Contact | 6144212151 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| National Church Residences Medical Home 2335 N Bank Dr Columbus OH 43220-5423 Ph: (614) 451-2151 | National Church Residences Medical Home 398 S Grant Ave Columbus OH 43215-5549 Ph: (614) 224-2988 |
| NPI Number | 1154692838 |
|---|---|
| Provider Enumeration Date | 01/26/2012 |
| Last Update Date | 02/09/2022 |
| Medicare PECOS PAC ID | 7012178171 |
|---|---|
| Medicare Enrollment ID | O20120417000255 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1154692838 | NPI | - | NPPES |
| 0062203 | Medicaid | OH |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207QA0505X | Family Medicine - Adult Medicine | NP07477 (Ohio) | Primary |
| Provider Name | Andrea Shields |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1205136207 PECOS PAC ID: 8022251404 Enrollment ID: I20130904000506 |
| Provider Name | Theresa L Reyes |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1346689254 PECOS PAC ID: 3577797372 Enrollment ID: I20131010000697 |
| Provider Name | Kawsu Conteh |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1124228226 PECOS PAC ID: 3678832623 Enrollment ID: I20180119001127 |
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