1366773921 NPI number — MR. PETER C KOMA C.R.N.A.

Table of content: MR. PETER C KOMA C.R.N.A. (NPI 1366773921)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366773921 NPI number — MR. PETER C KOMA C.R.N.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOMA
Provider First Name:
PETER
Provider Middle Name:
C
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
C.R.N.A.
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:
1366773921
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/24/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3622 BELMONT AVE
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
YOUNGSTOWN
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44505-1450
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-759-9350
Provider Business Mailing Address Fax Number:
330-759-9387

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3622 BELMONT AVE
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
YOUNGSTOWN
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44505-1450
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-759-9350
Provider Business Practice Location Address Fax Number:
330-759-9387
Provider Enumeration Date:
01/21/2010

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: 367500000X , with the licence number:  COA 11297 NA , 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: 301183 COA1 . This is a "RN" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 3022455 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 11297-NA . This is a "COA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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