1235135260 NPI number — MANDY A KLASS M.D.

Table of content: MANDY A KLASS M.D. (NPI 1235135260)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235135260 NPI number — MANDY A KLASS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KLASS
Provider First Name:
MANDY
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1235135260
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/18/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 636930
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45263-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-538-7330
Provider Business Mailing Address Fax Number:
419-538-7331

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 US 224
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
GLANDORF
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45848-0081
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-538-7330
Provider Business Practice Location Address Fax Number:
419-538-7331
Provider Enumeration Date:
06/23/2005

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: 207Q00000X , with the licence number:  083647 , 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: 9364531 . This is a "GROUP MEDICARE PIN" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2986729 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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