Provider Demographics
NPI:1073507901
Name:KOHL, JACK (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:
Last Name:KOHL
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3355 GLENDALE AVE
Mailing Address - Street 2:THIRD FLOOR
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-2426
Mailing Address - Country:US
Mailing Address - Phone:419-383-7100
Mailing Address - Fax:419-383-2000
Practice Address - Street 1:3000 ARLINGTON AVE
Practice Address - Street 2:ANTESTHSIA
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614-2595
Practice Address - Country:US
Practice Address - Phone:419-383-3556
Practice Address - Fax:419-383-3550
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN168859367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4344968Medicaid
OH4344968Medicaid
OHKO8203844Medicare ID - Type Unspecified