Basic Information
Provider Information
NPI: 1306238621
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: EBAUGH
FirstName: MICHAEL
MiddleName: PIERCE
NamePrefix:  
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Credential:  
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Mailing Information
Address1: 2920 W WALLCRAFT AVE
Address2:  
City: TAMPA
State: FL
PostalCode: 336111651
CountryCode: US
TelephoneNumber: 8135057610
FaxNumber:  
Practice Location
Address1: 5100 W BROAD ST
Address2: DOCTORS HOSPITAL
City: COLUMBUS
State: OH
PostalCode: 432281607
CountryCode: US
TelephoneNumber: 6145441000
FaxNumber: 6145441751
Other Information
ProviderEnumerationDate: 02/24/2015
LastUpdateDate: 03/18/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
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IsSoleProprietor: Y
IsOrganizationSubpart:  
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AuthorizedOfficialCredential:  
NPICertificationDate: 03/18/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207XX0004XS4133TXN Allopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
390200000X  Y Student, Health CareStudent in an Organized Health Care Education/Training Program 

No ID Information.


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