Provider Demographics
NPI:1780618413
Name:ALTER, KATHLEEN A (MD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:A
Last Name:ALTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2960 MACK RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-5373
Mailing Address - Country:US
Mailing Address - Phone:513-860-2777
Mailing Address - Fax:513-860-9507
Practice Address - Street 1:2960 MACK RD
Practice Address - Street 2:SUITE 210
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-5373
Practice Address - Country:US
Practice Address - Phone:513-860-2777
Practice Address - Fax:513-860-9507
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-05-0765207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0631427Medicaid
OH9331251Medicare PIN
OH0631427Medicaid