Provider Demographics
NPI:1982660239
Name:KASSICIEH, CHARLES V (DO)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:V
Last Name:KASSICIEH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6724 PERIMETER LOOP RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-3202
Mailing Address - Country:US
Mailing Address - Phone:614-975-5008
Mailing Address - Fax:614-792-2400
Practice Address - Street 1:6724 PERIMETER LOOP RD
Practice Address - Street 2:SUITE 202
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017-3202
Practice Address - Country:US
Practice Address - Phone:614-975-5008
Practice Address - Fax:614-792-2400
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34004319K207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0670591Medicaid
E59730Medicare UPIN
KA4123314Medicare ID - Type UnspecifiedMEDICARE FOR BERGER
OH0670591Medicaid