1073511010 NPI number — MR. BERTRAM HENSEL CRNA

Table of content: MR. BERTRAM HENSEL CRNA (NPI 1073511010)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073511010 NPI number — MR. BERTRAM HENSEL CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENSEL
Provider First Name:
BERTRAM
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073511010
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2914 S REPUBLIC BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOLEDO
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43615-1912
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-531-8808
Provider Business Mailing Address Fax Number:
419-531-9342

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
835 SWEITZER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENVILLE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45331-1007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-547-5723
Provider Business Practice Location Address Fax Number:
937-547-5784
Provider Enumeration Date:
07/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  129463 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0751020 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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