1356432926 NPI number — M & K FAMILY AND SPORTS MEDICINE, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356432926 NPI number — M & K FAMILY AND SPORTS MEDICINE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
M & K FAMILY AND SPORTS MEDICINE, 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:
1356432926
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/23/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 81
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLANDORF
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45848-0081
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:
Provider Business Practice Location Address City Name:
GLANDORF
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45848
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:
09/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MANSFIELD
Authorized Official First Name:
LINDA
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
419-538-7330

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DF2023 . This is a "MEDICARE RAILROAD GROUP" identifier . 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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