Provider Demographics
NPI:1275738551
Name:KNESEBECK, WAYNE S (PC)
Entity Type:Individual
Prefix:MR
First Name:WAYNE
Middle Name:S
Last Name:KNESEBECK
Suffix:
Gender:M
Credentials:PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 PARK AVE
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004-6887
Mailing Address - Country:US
Mailing Address - Phone:440-992-2121
Mailing Address - Fax:440-992-5974
Practice Address - Street 1:4200 PARK AVE
Practice Address - Street 2:3RD FLOOR
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-6887
Practice Address - Country:US
Practice Address - Phone:440-992-2121
Practice Address - Fax:440-992-5974
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOHIO LIC C0501083174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1851352959OtherGROUP NPI NUMBER
OH9295741Medicare ID - Type UnspecifiedMEDICARE NUMBER