1841497187 NPI number — DR. PETER MATTHEW KENNEDY DE BLANK M.D.

Table of content: DR. PETER MATTHEW KENNEDY DE BLANK M.D. (NPI 1841497187)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841497187 NPI number — DR. PETER MATTHEW KENNEDY DE BLANK M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DE BLANK
Provider First Name:
PETER
Provider Middle Name:
MATTHEW KENNEDY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1841497187
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/20/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3333 BURNET AVE
Provider Second Line Business Mailing Address:
MLC 7015
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45229-3026
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-636-4266
Provider Business Mailing Address Fax Number:
513-636-3549

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3333 BURNET AVE
Provider Second Line Business Practice Location Address:
MLC 7015
Provider Business Practice Location Address City Name:
CINCINNATI
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45229-3026
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-636-4266
Provider Business Practice Location Address Fax Number:
513-636-3549
Provider Enumeration Date:
06/29/2007

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: 208000000X , with the licence number:  MD431979 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080P0207X , with the licence number: 35.120364 , 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: 0075806 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 117515700 . 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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