1790906485 NPI number — KARL H JESKE DC

Table of content: KARL H JESKE DC (NPI 1790906485)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790906485 NPI number — KARL H JESKE DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JESKE
Provider First Name:
KARL
Provider Middle Name:
H
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DC
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:
1790906485
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/28/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5252 BROADVIEW RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PARMA
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44134-1630
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-882-3200
Provider Business Mailing Address Fax Number:
440-882-3201

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5252 BROADVIEW RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PARMA
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44134-1630
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-882-3200
Provider Business Practice Location Address Fax Number:
440-882-3201
Provider Enumeration Date:
05/01/2007

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: 111N00000X , with the licence number:  2972 , 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: 220835 . This is a "ANTHEM BCBS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 115575 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 610330100 . This is a "DEPT OF LABOR" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2226175 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 350050100 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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