1699896696 NPI number — DR. KATHLEENE ANNE SMACHLO M.D.

Table of content: DR. KATHLEENE ANNE SMACHLO M.D. (NPI 1699896696)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699896696 NPI number — DR. KATHLEENE ANNE SMACHLO M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMACHLO
Provider First Name:
KATHLEENE
Provider Middle Name:
ANNE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SMACHLO
Provider Other First Name:
KATHY
Provider Other Middle Name:
ANNE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1699896696
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2854 SEDGEWICK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHAKER HEIGHTS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44120-1838
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-751-6207
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10900 EUCLID AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44106-1712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-368-2457
Provider Business Practice Location Address Fax Number:
216-368-8548
Provider Enumeration Date:
04/03/2007

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: 207R00000X , with the licence number:  35050899-S , 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: 0709531 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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