Basic Information
| Provider Information | |||||||||
| NPI: | 1588648331 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KUNDTZ | ||||||||
| FirstName: | EWALD | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5700 DARROW RD | ||||||||
| Address2: | STE 106 | ||||||||
| City: | HUDSON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442365026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306569304 | ||||||||
| FaxNumber: | 3306565901 | ||||||||
| Practice Location | |||||||||
| Address1: | 13207 RAVENNA RD | ||||||||
| Address2: | |||||||||
| City: | CHARDON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440247032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402856000 | ||||||||
| FaxNumber: | 4402869686 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2005 | ||||||||
| LastUpdateDate: | 09/17/2008 | ||||||||
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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 | 207P00000X | 35060481K | OH | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1021545370001 | 05 | PA | MEDICAID | 000000385522 | 01 | OH | ANTHEM | OTHER | 000000269015 | 01 | OH | ANTHEM | OTHER | 000000557158 | 01 | OH | ANTHEM | OTHER | 0879143 | 05 | OH | MEDICAID |