Basic Information
| Provider Information | |||||||||
| NPI: | 1891736013 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PROVANZANA | ||||||||
| FirstName: | KATHLEEN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | # L-3652 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432600001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403837927 | ||||||||
| FaxNumber: | 7403837942 | ||||||||
| Practice Location | |||||||||
| Address1: | 6 LEXINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | DELAWARE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430151047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403633305 | ||||||||
| FaxNumber: | 7403837942 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 12/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35071152P | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0104351 | 01 | UHC | OTHER | 2074133 | 05 | OH | MEDICAID | 311098079 | 01 | TAX ID PHYS AND NON PHYS | OTHER | 353077 | 01 | SUBMITTER NO. | OTHER | 311098079 | 01 | TAX ID # | OTHER | 0855442 | 01 | PALMETTO MEDICARE | OTHER | 2025334 | 01 | AETNA | OTHER | 080122321 | 01 | TRAVELERS MEDICARE | OTHER | 311098079240 | 01 | CIGNA | OTHER |