Basic Information
| Provider Information | |||||||||
| NPI: | 1952513277 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KSENICH | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 636643 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452636643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409893801 | ||||||||
| FaxNumber: | 4409600264 | ||||||||
| Practice Location | |||||||||
| Address1: | 1120 E BROAD ST | ||||||||
| Address2: | |||||||||
| City: | ELYRIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440356306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403652600 | ||||||||
| FaxNumber: | 4403655543 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2007 | ||||||||
| LastUpdateDate: | 12/08/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35061954 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3025372 | 05 | OH | MEDICAID | 0868173 | 05 | OH | MEDICAID |