Provider Demographics
NPI:1639169493
Name:AUTUMN AEGIS, INC
Entity Type:Organization
Organization Name:AUTUMN AEGIS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:A
Authorized Official - Last Name:MALANOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-989-5200
Mailing Address - Street 1:3905 OBERLIN AVE
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44053-2838
Mailing Address - Country:US
Mailing Address - Phone:440-989-5200
Mailing Address - Fax:440-989-5273
Practice Address - Street 1:1130 TOWER BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44052-5235
Practice Address - Country:US
Practice Address - Phone:440-282-6768
Practice Address - Fax:440-960-5612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-24
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1039314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH70023800OtherBLACK LUNG
OH0323733Medicaid
OH000000156349OtherANTHEM
OH000000357077OtherANTHEM PT
OH000000357078OtherANTHEM OT
OH000000357079OtherANTHEM ST
OH0323733Medicaid
OH000000357079OtherANTHEM ST
OH000000357078OtherANTHEM OT