=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609841964
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THEODORE K KRUTKY M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2006
-----------------------------------------------------
Last Update Date | 07/09/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 802 GRAHAM RD
-----------------------------------------------------
City | CUYAHOGA FALLS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44221-1049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-929-4221
-----------------------------------------------------
Fax | 330-929-7513
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 26125
-----------------------------------------------------
City | AKRON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44319-6125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-719-9020
-----------------------------------------------------
Fax | 330-493-7123
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 35039773
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------