1083697585 NPI number — CHRISTINE ANN ZIDEK CNP

Table of content: CHRISTINE ANN ZIDEK CNP (NPI 1083697585)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083697585 NPI number — CHRISTINE ANN ZIDEK CNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ZIDEK
Provider First Name:
CHRISTINE
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CNP
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:
1083697585
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/06/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1240 RAVELLE CT
Provider Second Line Business Mailing Address:
BELLBROOK
Provider Business Mailing Address City Name:
BELLBROOK
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45305-8760
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-848-7372
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3033 KETTERING BLVD
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
MORAINE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45439-1962
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-293-2133
Provider Business Practice Location Address Fax Number:
937-293-2161
Provider Enumeration Date:
11/29/2005

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: 363L00000X , with the licence number:  NP05623 , 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: 2305777 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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