Provider Demographics
NPI:1023231602
Name:PERSONAL MD, LLC
Entity type:Organization
Organization Name:PERSONAL MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:MILKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-933-9100
Mailing Address - Street 1:5121 FOREST DRIVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:NEW ALBANY
Mailing Address - State:OH
Mailing Address - Zip Code:43054-7102
Mailing Address - Country:US
Mailing Address - Phone:614-933-9100
Mailing Address - Fax:614-933-9103
Practice Address - Street 1:5121 FOREST DRIVE
Practice Address - Street 2:SUITE D
Practice Address - City:NEW ALBANY
Practice Address - State:OH
Practice Address - Zip Code:43054-7102
Practice Address - Country:US
Practice Address - Phone:614-933-9100
Practice Address - Fax:614-933-9103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-045924174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9365321Medicare PIN
OHA79981Medicare UPIN