Basic Information
| Provider Information | |||||||||
| NPI: | 1568532620 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHAKER CLINIC, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | OHIO CLINIC FOR PSYCHIATRY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6100 TOWER CIR STE 1000 | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370671509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158616000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 899 E BROAD ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432051156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6149289400 | ||||||||
| FaxNumber: | 6149289401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2006 | ||||||||
| LastUpdateDate: | 09/25/2018 | ||||||||
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| AuthorizedOfficialLastName: | HOWARD | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | VP & SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 6158616000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 0519 | OH | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 2428868 | 05 | OH | MEDICAID | 9342121 | 01 | OH | MEDICARE OTHER | OTHER |