Healthcare Provider Details

I. General information

NPI: 1194296947
Provider Name (Legal Business Name): KYLE ROBERT HEGEDUS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2018
Last Update Date: 12/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 UNIVERSITY PLZ
YOUNGSTOWN OH
44555-0001
US

IV. Provider business mailing address

15933 ASHLAND DR
BROOKPARK OH
44142-1915
US

V. Phone/Fax

Practice location:
  • Phone: 330-941-3000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: