Healthcare Provider Details

I. General information

NPI: 1275738551
Provider Name (Legal Business Name): WAYNE S. KNESEBECK P.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 PARK AVE 3RD FLOOR
ASHTABULA OH
44004-6887
US

IV. Provider business mailing address

4200 PARK AVE 3RD FLOOR
ASHTABULA OH
44004-6887
US

V. Phone/Fax

Practice location:
  • Phone: 440-992-2121
  • Fax: 440-992-5974
Mailing address:
  • Phone: 440-992-2121
  • Fax: 440-992-5974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberOHIO LIC C0501083
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: