Provider Demographics
NPI:1962564401
Name:BRENDA J SICKLE SANTANELLO MD INC
Entity type:Organization
Organization Name:BRENDA J SICKLE SANTANELLO MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BURK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-505-7508
Mailing Address - Street 1:8100 RAVINES EDGE CT
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43235
Mailing Address - Country:US
Mailing Address - Phone:614-505-7510
Mailing Address - Fax:614-505-7512
Practice Address - Street 1:8100 RAVINES EDGE CT
Practice Address - Street 2:SUITE 100
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43235
Practice Address - Country:US
Practice Address - Phone:614-505-7510
Practice Address - Fax:614-505-7512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
OH35050732174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2251405Medicaid
OH9315351Medicare ID - Type Unspecified