Basic Information
| Provider Information | |||||||||
| NPI: | 1649416504 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LI | ||||||||
| FirstName: | NA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 ACKERMAN RD | ||||||||
| Address2: | SUITE 570 | ||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432021559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142932594 | ||||||||
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| Practice Location | |||||||||
| Address1: | 410 W 10TH AVE | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432101240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142936255 | ||||||||
| FaxNumber: | 6142938518 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2008 | ||||||||
| LastUpdateDate: | 06/01/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 174400000X | 259651 | NY | N | Other Service Providers | Specialist | 207RG0100X | 35.120640 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | OH | MEDICAID |