Provider Demographics
NPI:1184793002
Name:PICKAWAY PROFESSIONAL SERVICES INC
Entity type:Organization
Organization Name:PICKAWAY PROFESSIONAL SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLTEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:614-552-0061
Mailing Address - Street 1:PO BOX 71-4823
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43271-4823
Mailing Address - Country:US
Mailing Address - Phone:614-552-0061
Mailing Address - Fax:614-552-0168
Practice Address - Street 1:600 N PICKAWAY ST
Practice Address - Street 2:
Practice Address - City:CIRCLEVILLE
Practice Address - State:OH
Practice Address - Zip Code:43113-1447
Practice Address - Country:US
Practice Address - Phone:740-474-2124
Practice Address - Fax:614-552-0068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2347259Medicaid
OH2347259Medicaid