Provider Demographics
NPI:1720384381
Name:BIELEWICZ, LORAN KIMBERLY (PA)
Entity Type:Individual
Prefix:
First Name:LORAN
Middle Name:KIMBERLY
Last Name:BIELEWICZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LORAN
Other - Middle Name:KIMBERLY
Other - Last Name:CARROLL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 636324
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6324
Mailing Address - Country:US
Mailing Address - Phone:859-344-5555
Mailing Address - Fax:859-344-5552
Practice Address - Street 1:1 MEDICAL VILLAGE DR
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-3403
Practice Address - Country:US
Practice Address - Phone:859-301-9010
Practice Address - Fax:859-301-9018
Is Sole Proprietor?:No
Enumeration Date:2011-01-31
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.003277363A00000X
OH50.003227363AS0400X
KYTC139363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0072074Medicaid
OHPA37551Medicare PIN