1922629302 NPI number — SAMANTHA KALTENBACH PA-C

Table of content: SAMANTHA KALTENBACH PA-C (NPI 1922629302)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922629302 NPI number — SAMANTHA KALTENBACH PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KALTENBACH
Provider First Name:
SAMANTHA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DUMBAULD
Provider Other First Name:
SAMANTHA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1922629302
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/21/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 746747
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30374-6747
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
666-808-5058
Provider Business Mailing Address Fax Number:
374-364-1569

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
131 LEWIS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CIRCLEVILLE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43113-1209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-539-1800
Provider Business Practice Location Address Fax Number:
617-263-3376
Provider Enumeration Date:
04/27/2020

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: 363A00000X , with the licence number:  50.008954RX , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X , with the licence number: 9115222 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 113187400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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