Healthcare Provider Details

I. General information

NPI: 1952600967
Provider Name (Legal Business Name): KENNETH M SCHWALLIE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2011
Last Update Date: 03/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2139 AUBURN AVE
CINCINNATI OH
45219-2906
US

IV. Provider business mailing address

225 W. MICHIGAN AVENUE PO BOX 1123
JACKSON MI
49204-1123
US

V. Phone/Fax

Practice location:
  • Phone: 513-585-2000
  • Fax: 513-612-4479
Mailing address:
  • Phone: 800-516-5315
  • Fax: 517-787-7365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberNA.12150
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: