Provider Demographics
NPI:1194924431
Name:JACK STANKO MD LLC
Entity type:Organization
Organization Name:JACK STANKO MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-996-8011
Mailing Address - Street 1:147 SCHOOLHOUSE LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43228-1214
Mailing Address - Country:US
Mailing Address - Phone:614-996-8011
Mailing Address - Fax:614-996-8015
Practice Address - Street 1:147 SCHOOLHOUSE LN
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43228-1214
Practice Address - Country:US
Practice Address - Phone:614-996-8011
Practice Address - Fax:614-996-8015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-17
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0063802Medicaid
OH0063802Medicaid