Provider Demographics
NPI:1104643634
Name:MYLAUREL MEDICAL GROUP OH, LLC
Entity type:Organization
Organization Name:MYLAUREL MEDICAL GROUP OH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:BRANKO
Authorized Official - Middle Name:
Authorized Official - Last Name:KOLVEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-497-2452
Mailing Address - Street 1:885 3RD AVE FL 29
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-4834
Mailing Address - Country:US
Mailing Address - Phone:866-619-7803
Mailing Address - Fax:
Practice Address - Street 1:1201 DUBLIN RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-1045
Practice Address - Country:US
Practice Address - Phone:886-619-7803
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-25
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty