Basic Information
| Provider Information | |||||||||
| NPI: | 1073950895 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELZER | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | STEPHEN | ||||||||
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| Credential: | PA-S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 W MAIN ST STE 330 | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453733384 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9379807400 | ||||||||
| FaxNumber: | 9379807409 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 S STANFIELD RD STE A | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373395355 | ||||||||
| FaxNumber: | 9373393056 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2013 | ||||||||
| LastUpdateDate: | 01/20/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 363A00000X | 50.003850RX | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0096509 | 05 | OH | MEDICAID |