1255334272 NPI number — GARY R KUTSIKOVICH M.D.

Table of content: RAINEY CELEST THOMAS (NPI 1497511737)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255334272 NPI number — GARY R KUTSIKOVICH M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KUTSIKOVICH
Provider First Name:
GARY
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1255334272
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/13/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8224 MENTOR AVE
Provider Second Line Business Mailing Address:
STE 126
Provider Business Mailing Address City Name:
MENTOR
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44060-5768
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-205-9292
Provider Business Mailing Address Fax Number:
440-205-9191

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8224 MENTOR AVE
Provider Second Line Business Practice Location Address:
STE 126
Provider Business Practice Location Address City Name:
MENTOR
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44060-5768
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-205-9292
Provider Business Practice Location Address Fax Number:
440-205-9191
Provider Enumeration Date:
05/23/2005

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: 2084N0400X , with the licence number:  35081014K , 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: 2475487 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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