Provider Demographics
NPI:1003448531
Name:KISER, MATTHEW GORDAN
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:GORDAN
Last Name:KISER
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 1:3341 STATE ROUTE 44
Mailing Address - Street 2:
Mailing Address - City:ROOTSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44272-9687
Mailing Address - Country:US
Mailing Address - Phone:330-577-6108
Mailing Address - Fax:
Practice Address - Street 1:3341 STATE ROUTE 44
Practice Address - Street 2:
Practice Address - City:ROOTSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44272-9687
Practice Address - Country:US
Practice Address - Phone:330-577-6108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-12
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0377875Medicaid