1639169493 NPI number — AUTUMN AEGIS, INC

Table of content: (NPI 1639169493)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639169493 NPI number — AUTUMN AEGIS, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AUTUMN AEGIS, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1639169493
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/19/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3905 OBERLIN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LORAIN
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44053-2838
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-989-5200
Provider Business Mailing Address Fax Number:
440-989-5273

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1130 TOWER BLVD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
LORAIN
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44052-5235
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-282-6768
Provider Business Practice Location Address Fax Number:
440-960-5612
Provider Enumeration Date:
10/24/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MALANOWSKI
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
440-989-5200

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  1039 , 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: 70023800 . This is a "BLACK LUNG" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0323733 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000156349 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000357077 . This is a "ANTHEM PT" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000357078 . This is a "ANTHEM OT" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000357079 . This is a "ANTHEM ST" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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