1356338487 NPI number — KEVIN K KOFFEL M.D.

Table of content: KEVIN K KOFFEL M.D. (NPI 1356338487)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356338487 NPI number — KEVIN K KOFFEL M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOFFEL
Provider First Name:
KEVIN
Provider Middle Name:
K
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:
1356338487
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3439 GRANITE CIR
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:
43617-1161
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-843-7996
Provider Business Mailing Address Fax Number:
419-841-7725

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3439 GRANITE CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TOLEDO
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43617-1161
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-843-7996
Provider Business Practice Location Address Fax Number:
419-841-7725
Provider Enumeration Date:
10/04/2005

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: 207RG0100X , with the licence number:  35045739K , 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: 4037439 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00267 . This is a "PARAMOUNT" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0479781 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00659824 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000581405 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".




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