Basic Information
| Provider Information | |||||||||
| NPI: | 1528200482 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KLAUSING | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 SAINT CLAIR AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT MARYS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458852400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193001129 | ||||||||
| FaxNumber: | 4193949575 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 PRO DR STE D4 | ||||||||
| Address2: | |||||||||
| City: | CELINA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458223307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195866480 | ||||||||
| FaxNumber: | 4195864125 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2009 | ||||||||
| LastUpdateDate: | 08/07/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 08/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 50.002892RX | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1184652539 | 01 | OH | JTDM FAMILY PRACTICE, LLC GROUP NPI | OTHER | 9934723 | 01 | OH | JTDM FAMILY PRACTICE, LLC GROUP MEDICARE PTAN | OTHER | H409552 | 01 | MEDICARE PTAN | OTHER | 0105065 | 01 | OH | JTDM FAMILY PRACTICE, LLC GROUP MEDICAID | OTHER | 0075276 | 05 | OH | MEDICAID | 34-1689161 | 01 | OH | JTDM FAMILY PRACTICE, LLC TAX ID | OTHER |