1386641454 NPI number — PETER KANISTROS MD

Table of content: PETER KANISTROS MD (NPI 1386641454)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386641454 NPI number — PETER KANISTROS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KANISTROS
Provider First Name:
PETER
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1386641454
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1331 N ELM ST
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
GREENSBORO
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27401-6302
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-274-9617
Provider Business Mailing Address Fax Number:
336-482-2177

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4983 DELHI AVE
Provider Second Line Business Practice Location Address:
SUITE 6
Provider Business Practice Location Address City Name:
CINCINNATI
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45238-5380
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-347-7237
Provider Business Practice Location Address Fax Number:
513-347-6567
Provider Enumeration Date:
07/05/2005

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: 2085R0202X , with the licence number:  35072707K , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085N0904X , with the licence number: 35072703 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 200938470 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2034622 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com