Basic Information
| Provider Information | |||||||||
| NPI: | 1245658533 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAYSLEY | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | ALLEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 932759 | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441930015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372938228 | ||||||||
| FaxNumber: | 9372938229 | ||||||||
| Practice Location | |||||||||
| Address1: | 4881 SUGAR MAPLE DR | ||||||||
| Address2: | 88 MEDICAL GROUP/88 SGC | ||||||||
| City: | WRIGHT PATTERSON AFB | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454335529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372570837 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2014 | ||||||||
| LastUpdateDate: | 06/15/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171000000X | N | Other Service Providers | Military Health Care Provider | 207L00000X | 52648 | KY | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 35.137187 | OH | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 7100362040 | 05 | KY | MEDICAID |