1427075415 NPI number — KELLY A SIEGEL CNP

Table of content: KELLY A SIEGEL CNP (NPI 1427075415)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427075415 NPI number — KELLY A SIEGEL CNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SIEGEL
Provider First Name:
KELLY
Provider Middle Name:
A
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:
1427075415
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/01/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9485 MENTOR AVE SUITE 210
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MENTOR
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44060
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-255-5571
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9485 MENTOR AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MENTOR
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44060-1716
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-255-5571
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/16/2006

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:  NP-04339 , 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: 2160683 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000224469 . This is a "UNISON" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000539712 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 740018 . This is a "BUCKEYE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 746018 . This is a "BUCKEYE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 364120 . This is a "WELLCARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 7240712 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".




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