Provider Demographics
NPI:1659453876
Name:CONCORDIA OF OHIO
Entity Type:Organization
Organization Name:CONCORDIA OF OHIO
Other - Org Name:CONCORDIA AT SUMNER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CHARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:KISH
Authorized Official - Suffix:
Authorized Official - Credentials:LNA
Authorized Official - Phone:330-664-1360
Mailing Address - Street 1:970 SUMNER PKWY
Mailing Address - Street 2:
Mailing Address - City:COPLEY
Mailing Address - State:OH
Mailing Address - Zip Code:44321-1693
Mailing Address - Country:US
Mailing Address - Phone:330-664-1360
Mailing Address - Fax:330-664-1197
Practice Address - Street 1:970 SUMNER PKWY
Practice Address - Street 2:
Practice Address - City:COPLEY
Practice Address - State:OH
Practice Address - Zip Code:44321-1693
Practice Address - Country:US
Practice Address - Phone:330-664-1360
Practice Address - Fax:330-664-1197
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CONCORDIA LUTHERN MINISTRIES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-19
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2389N313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0073403Medicaid
OH366289Medicare Oscar/Certification