Basic Information
| Provider Information | |||||||||
| NPI: | 1750654059 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOTHWELL | ||||||||
| FirstName: | VIRGINIA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | CRNA, DNAP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5151 REED RD | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432202553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144572306 | ||||||||
| FaxNumber: | 6148840776 | ||||||||
| Practice Location | |||||||||
| Address1: | 5151 REED RD | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432202553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144572306 | ||||||||
| FaxNumber: | 6148840776 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2012 | ||||||||
| LastUpdateDate: | 02/25/2014 | ||||||||
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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 | 367500000X | AC001005 | MD | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | COA 14479-NA | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | P01209409 | 01 | OH | MEDICARE RAILROAD | OTHER | 0085436 | 05 | OH | MEDICAID |