Provider Demographics
NPI:1689871220
Name:KENT STATE UNIVERSITY
Entity Type:Organization
Organization Name:KENT STATE UNIVERSITY
Other - Org Name:KENT STATE UNIVERSITY SPEECH & HEARING CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VP FINANCE & ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:M
Authorized Official - Last Name:POLATAJKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-672-2422
Mailing Address - Street 1:1325 THEATRE DR A126 CENTER FOR THE PERFORMING ARTS
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:OH
Mailing Address - Zip Code:44242-0001
Mailing Address - Country:US
Mailing Address - Phone:330-672-0250
Mailing Address - Fax:330-672-2643
Practice Address - Street 1:1325 THEATRE DR A126 CENTER FOR THE PERFORMING ARTS
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:OH
Practice Address - Zip Code:44242-0001
Practice Address - Country:US
Practice Address - Phone:330-672-0250
Practice Address - Fax:330-672-2643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-28
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4644504Medicaid