MEDICARE: KEVIN JAMES WADE QMHS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator		OH

General Provider Information

NPI Number	:	1740011758
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN JAMES WADE QMHS

Provider Business Mailing Address
First Line	:	104 JAVIT CT
Second Line	:
City	:	AUSTINTOWN
State	:	OH
Zip	:	44515-2439
Country	:	US
Telephone Number	:	330-797-4050
Fax Number	:

Provider Business Practice Location Address
First Line	:	49 S LAKEVIEW AVE
Second Line	:
City	:	YOUNGSTOWN
State	:	OH
Zip	:	44509-2804
Country	:	US
Telephone Number	:	414-379-5170
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/12/2024
Last Update Date	:	10/18/2024

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