Provider Demographics
NPI:1962455196
Name:OHIO SPORTS & SPINE INSTITUTE, LTD
Entity Type:Organization
Organization Name:OHIO SPORTS & SPINE INSTITUTE, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KLEEH
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:330-758-9400
Mailing Address - Street 1:1265 BOARDMAN CANFIELD RD
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-4004
Mailing Address - Country:US
Mailing Address - Phone:330-758-9400
Mailing Address - Fax:330-726-8676
Practice Address - Street 1:1265 BOARDMAN CANFIELD RD
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-4004
Practice Address - Country:US
Practice Address - Phone:330-758-9400
Practice Address - Fax:330-726-8676
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH34004337204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9276652Medicare PIN
OH9276651Medicare PIN
OH9276653Medicare PIN