Basic Information
| Provider Information | |||||||||
| NPI: | 1508059825 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CASEBOLT | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | PATRICK | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 636372 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452630001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192269120 | ||||||||
| FaxNumber: | 4199965410 | ||||||||
| Practice Location | |||||||||
| Address1: | 967 BELLEFONTAINE AVE | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458042888 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199965895 | ||||||||
| FaxNumber: | 4199965896 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2007 | ||||||||
| LastUpdateDate: | 06/28/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | COA.09536 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 2795060 | 05 | OH | MEDICAID | 1 | 01 | OH | NO BILLING NUMBERS | OTHER |