Provider Demographics
NPI:1083779110
Name:KENTON FAMILY PRACTICE LLC
Entity Type:Organization
Organization Name:KENTON FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:D
Authorized Official - Last Name:WESSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:419-675-1962
Mailing Address - Street 1:PO BOX 418
Mailing Address - Street 2:
Mailing Address - City:KENTON
Mailing Address - State:OH
Mailing Address - Zip Code:43326-0418
Mailing Address - Country:US
Mailing Address - Phone:419-675-1962
Mailing Address - Fax:419-673-8058
Practice Address - Street 1:75 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:KENTON
Practice Address - State:OH
Practice Address - Zip Code:43326-4001
Practice Address - Country:US
Practice Address - Phone:419-675-1962
Practice Address - Fax:419-673-8058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0174289Medicaid
OH0174289Medicaid
OH4106952Medicare PIN