Provider Demographics
NPI:1972834307
Name:WILLIAM KEGERIZE OD LLC
Entity Type:Organization
Organization Name:WILLIAM KEGERIZE OD LLC
Other - Org Name:GENOA FAMILY EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:R
Authorized Official - Last Name:KEGERIZE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:419-855-3640
Mailing Address - Street 1:603 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GENOA
Mailing Address - State:OH
Mailing Address - Zip Code:43430-1635
Mailing Address - Country:US
Mailing Address - Phone:419-855-3640
Mailing Address - Fax:419-855-4743
Practice Address - Street 1:603 MAIN ST
Practice Address - Street 2:
Practice Address - City:GENOA
Practice Address - State:OH
Practice Address - Zip Code:43430-1635
Practice Address - Country:US
Practice Address - Phone:419-855-3640
Practice Address - Fax:419-855-4743
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WILLIAM KEGERIZE OD LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-01-25
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH5558302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3037403Medicaid
OHDU5970Medicare PIN
OH3037403Medicaid
OH6495310001Medicare NSC