Provider Demographics
NPI:1740399310
Name:KILBANE, MARTIN
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:KILBANE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19470 LAUREL AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKY RIVER
Mailing Address - State:OH
Mailing Address - Zip Code:44116-2708
Mailing Address - Country:US
Mailing Address - Phone:440-333-2396
Mailing Address - Fax:
Practice Address - Street 1:671 COLUMBIA RD
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-1477
Practice Address - Country:US
Practice Address - Phone:440-871-7767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPT09266OtherLICENSE#