=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730429192
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KSPMD LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2013
-----------------------------------------------------
Last Update Date | 10/04/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 45 MCCLURG RD
-----------------------------------------------------
City | BOARDMAN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44512-6737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-565-6754
-----------------------------------------------------
Fax | 330-746-1315
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 45 MCCLURG RD
-----------------------------------------------------
City | BOARDMAN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44512-6737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-565-6754
-----------------------------------------------------
Fax | 330-746-1315
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | KATHLEEN S PADGITT
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 888-565-6754
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 35.060428
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------