Healthcare Provider Details

I. General information

NPI: 1780641415
Provider Name (Legal Business Name): JEREMY M KALTENBACH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 04/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 23RD ST STE G30
ASHLAND KY
41101-2881
US

IV. Provider business mailing address

2828 1ST AVE SUITE 400
HUNTINGTON WV
25702-1236
US

V. Phone/Fax

Practice location:
  • Phone: 606-327-0036
  • Fax: 606-327-0036
Mailing address:
  • Phone: 304-525-6905
  • Fax: 304-525-4316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number943
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number00943
License Number StateWV
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number50.001490
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA1816
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: