Basic Information
| Provider Information | |||||||||
| NPI: | 1376599597 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIMITRIS | ||||||||
| FirstName: | KELLY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1649 | ||||||||
| Address2: | |||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443091649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308648900 | ||||||||
| FaxNumber: | 3308698924 | ||||||||
| Practice Location | |||||||||
| Address1: | 525 E MARKET ST | ||||||||
| Address2: | |||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443041619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303753369 | ||||||||
| FaxNumber: | 3303753769 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 35082869 | OH | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2456908 | 05 | OH | MEDICAID | 341779226003 | 01 | OH | MED MUTUAL OH 2 OF 3 | OTHER | 341779226006 | 01 | OH | MED MUTUAL OF OH 3 OF 3 | OTHER | 00000031642 | 01 | OH | ANTHEM | OTHER | 61641 | 01 | OH | UNITED HEALTCARE | OTHER | 341779226002 | 01 | OH | MED MUTUAL OH 1 OF 3 | OTHER |