Healthcare Provider Details

I. General information

NPI: 1952513277
Provider Name (Legal Business Name): NICHOLAS J KSENICH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 12/08/2020
Certification Date: 12/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 E BROAD ST
ELYRIA OH
44035-6306
US

IV. Provider business mailing address

PO BOX 636643
CINCINNATI OH
45263-6643
US

V. Phone/Fax

Practice location:
  • Phone: 440-365-2600
  • Fax: 440-365-5543
Mailing address:
  • Phone: 440-989-3801
  • Fax: 440-960-0264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35061954
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: