Basic Information
| Provider Information | |||||||||
| NPI: | 1710979117 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANDY | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 555 S 18TH ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432052654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147224559 | ||||||||
| FaxNumber: | 6147224541 | ||||||||
| Practice Location | |||||||||
| Address1: | 555 S 18TH ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432052654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147224559 | ||||||||
| FaxNumber: | 6147224541 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2005 | ||||||||
| LastUpdateDate: | 11/06/2008 | ||||||||
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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 | 2080N0001X | 35083634 | OH | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64085855 | 05 | KY | MEDICAID | 2321526 | 05 | OH | MEDICAID |