1427320266 NPI number — KEVIN J MASTERSON MD INC

Table of content: DR. WILLIAM B. BISLAND JR. MD (NPI 1285824847)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427320266 NPI number — KEVIN J MASTERSON MD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KEVIN J MASTERSON MD 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:
6
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:
1427320266
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/08/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20455 LORAIN RD.
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
FAIRVIEW PARK
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44126-3529
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-356-5477
Provider Business Mailing Address Fax Number:
440-356-5885

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20455 LORAIN RD
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
FAIRVIEW PARK
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44126-3529
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-356-5477
Provider Business Practice Location Address Fax Number:
440-356-5885
Provider Enumeration Date:
02/08/2012

Additional Information

Authorized Official

Authorized Official Last Name:
MASTERSON
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
440-356-5477

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  35-04-5048-M , 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: 0481554 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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