Basic Information
| Provider Information | |||||||||
| NPI: | 1922199496 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLACHIS | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | CONSTANTIN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 ACKERMAN RD STE 2120 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432021559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142932594 | ||||||||
| FaxNumber: | 6142934487 | ||||||||
| Practice Location | |||||||||
| Address1: | 2050 KENNY RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432213502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143669211 | ||||||||
| FaxNumber: | 6143662210 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 12/28/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081S0010X | 35052282C | OH | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Sports Medicine | 208100000X | 35052282C | OH | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 0683023 | 05 | OH | MEDICAID |