Basic Information
| Provider Information | |||||||||
| NPI: | 1194806430 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KHANDELWAL | ||||||||
| FirstName: | SORABH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 ACKERMAN RD | ||||||||
| Address2: | STE 570 | ||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432021579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142932594 | ||||||||
| FaxNumber: | 6142934487 | ||||||||
| Practice Location | |||||||||
| Address1: | 410 W 10TH AVE | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432101240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142938305 | ||||||||
| FaxNumber: | 6142933124 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 06/18/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0005X | 35072170 | OH | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Undersea and Hyperbaric Medicine | 207P00000X | 35072170 | OH | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2094684 | 05 | OH | MEDICAID | 311229292 | 01 | OH | GROUP FEDERAL TAX ID# | OTHER |