Provider Demographics
NPI:1821058975
Name:BUCHHOLZ, KURT ROGER (PAC)
Entity Type:Individual
Prefix:
First Name:KURT
Middle Name:ROGER
Last Name:BUCHHOLZ
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6115 POWERS BLVD
Mailing Address - Street 2:STE. 100
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44129-5471
Mailing Address - Country:US
Mailing Address - Phone:440-842-1570
Mailing Address - Fax:440-842-8230
Practice Address - Street 1:6115 POWERS BLVD
Practice Address - Street 2:STE. 100
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44129-5471
Practice Address - Country:US
Practice Address - Phone:440-842-1570
Practice Address - Fax:440-842-8230
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-00-1658363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP52960Medicare UPIN
OH18715Medicare PIN
OH18716Medicare PIN